DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
010169 A. BUILDING __________
B. WING ______________ 		11/30/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ATMORE COMMUNITY HOSPITAL 401 MEDICAL PARK DRIVE, ATMORE, AL, 36502
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E0037 Ep Training Program
Corrected On: 01/19/2024
30952 Based on review of the employee files, and interview with the staff it was determined the facility failed to ensure contracted staff completed the initial Emergency Preparedness (EP) training. This deficient practice did affect one of two contract employee files reviewed, including Employee Identifier (EI) # 6, Director of Culinary Services and had the potential to negatively affect all staff and patients served by the clinic. Findings include: 1. A review of employee files conducted on 11/30/23 revealed EI # 6 was hired on 2/20/23. There was no documentation EI # 6 had received initial training in emergency preparedness. An interview was conducted on 11/30/23 at 12:02 PM with EI # 1, Registered Nurse Manager, who confirmed EI # 6 had not received initial emergency preparedness training.