Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 65C0001001 (X3) Date Survey Completed 02/08/2019
Name of Provider or Supplier Hafa Adai Specialist Group, Llp Street Address, City, State Sunflower Villa, 280 Pale San Vitores, Tamuning, GU
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
E0029 Development of Communication Plan
CFR(s): 416.54(c)

§403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities].


This STANDARD is not met as evidenced by:
Based on interview with the facility's office manager and document review of the emergency preparedness plan the facility's emergency preparedness plan does not include a written communication plan. Without such a plan the facility has no assurance that they will be able to communicate with outside sources of help during an emergency.



This could delay patient evacuation efforts to facilities that may still have the means to care for patients. It could also delay the passing of requests for medical or other supplies from outside entities. Staff, including volunteers, and physicians could not be notified promptly. This could affect all of the facility's patients and staff

.

Findings:



On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's emergency preparedness program no communication plan was observed. The office manager confirmed that the emergency preparedness program did not include a communication plan.