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 017050 (X3) Date Survey Completed 01/06/2023
Name of Provider or Supplier Central North Alabama Health Services, Inc. Street Address, City, State 1310 Pulaski Pike, Unit A, Huntsville, AL
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)
E0024 Policies/Procedures-Volunteers and Staffing
CFR(s): 484.102(b)(5)

§403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.


This STANDARD is not met as evidenced by:
Based on review of the Emergency Preparedness (EP) Program, list of current agency personnel, and staff interview it was determined the agency failed to develop policies and procedures for emergency staffing strategies during an emergency.


Findings include:


Review of the agency EP program revealed there were no policies or procedures for emergency staffing strategies during an emergency in the event the RN was unavailable.


Review of the list of current personnel provided by the agency on 1/6/23 revealed:



One Full Time (FT) RN
One Part Time (PT) LPN
One FT Physical Therapist
One FT Occupational Therapist
Two contract Occupational Therapy Assistants
One contract Speech Pathologist

There was only one SN to make all ordered/needed nursing visits for the agency.


An interview was conducted on 1/4/23 with Employee Identifier (EI) # 1, Registered Nurse (RN) Administrator regarding the agency's processes of operation. During the interview, EI # 1 confirmed he/she was the only Skilled Nurse (SN) that made Home Visits (HV) for the agency, and there was a Licensed Practical Nurse (LPN) that worked elsewhere during the day and did not make HV's for patients.


During the review of the agency's EP program on 1/6/23 at 12:45 PM with EI # 3, Operations Manager, EI # 3 confirmed the agency had no emergency staffing policies and procedures.