Survey Report for 061305

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	061305	A. BUILDING __________ B. WING ______________	09/20/2023
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
MELISSA MEMORIAL HOSPITAL	1001 E JOHNSON ST, HOLYOKE, CO, 80734
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)
E0004	Develop Ep Plan, Review And Update Annually Corrected On: 10/12/2023
E0004	49541 Based on document review and interviews, the facility failed to maintain an emergency preparedness plan which was reviewed and updated every two years. Findings include: Facility policy: According to the Emergency Preparedness Plan policy, the Emergency Preparedness Plan will be evaluated annually in terms of its objectives, scope, performance and effectiveness. 1. The facility failed to ensure its emergency preparedness plan was reviewed and updated every two years. a. On 09/18/2023 12:01 p.m., a request was made for the facility's emergency preparedness plan. On review of the document provided, it was dated May 2021, two years and eight months prior to the survey and four months past the required update. b. On 09/20/2023 at 10:30 p.m., the chief compliance officer (Director) #3 was interviewed. Director #3 stated the facility had not updated the emergency preparedness (EP) plan since 2021; however, they were in the process of rewriting the EP. Director #3 stated an updated emergency plan was important to ensure staff and patients were safe during an emergency situation.