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 52P002 (X3) Date Survey Completed 03/24/2022
Name of Provider or Supplier Versiti Wisconsin Street Address, City, State 638 North 18th Street, Milwaukee, WI
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)
E0031 Emergency Officials Contact Information

§403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency.


This STANDARD is not met as evidenced by:
Based on document review and interview the Organ Procurement Organization (OPO) failed to ensure the OPO Disaster Control communication plan included means for contact with Federal, State, Tribal, Regional and local emergency management agencies. Findings include: Review of the documents titled 1) "Versiti Organ and Tissue Procurement Emergency Preparedness Plan" effective date: 12/27/21 Version 8-BCP00544 "Communication Plan" effective 11/1/16 Version 6-BCP01000 "Organ, Tissue and Eye Procurement Key Contacts List" effective 12/27/21 Version 8-BCP90005 revealed no evidence of contact information of any Federal, State, Tribal, Regional or local emergency management agencies. On 03/23/2022 E1 was interviewed at 9:50 am. and she/he confirmed the plan did not include contact information of any Federal, State, Tribal, Regional or local emergency management agencies.