River Park Hospital – The Roundtable Program

Deficiency cited, recertification survey : E 001 Establishment of the Emergency Program (EP)

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to have an Emergency Preparedness Plan (EPP) which was specific to the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency.

Deficiency cited, recertification survey : E 004 Develop EP Plan, Review and Update Annually

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an Emergency Preparedness Plan (EPP) which was specific to the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility EPP revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 006 Plan Based on All Hazards Risk Assessment

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an Emergency Preparedness Plan (EPP) that was based on and included a facility- based and community-based risk assessment utilizing an all-hazards approach specific to the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility EPP revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 007 EP Program Patient Population

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an Emergency Preparedness Plan (EPP) that addressed the patient/client population including persons at risk, the type of services the PRTF has the ability to provide in an emergency and continuity of operations including delegations of authority and succession plans. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility EPP revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 009 Local, State, Tribal Collaboration Process

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an Emergency Preparedness Plan (EPP) that included a process for cooperation and collaboration with local, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility EPP revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 013 Development of EP Policies and Procedures

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 015 Subsistence Needs for Staff and Patients

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for the PRTF based on the emergency plan, the risk assessment and the communication plan. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 018 Procedures for Tracking of Staff and Patients

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for the tracking of patients and staff specific to the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 020 Policies for Evac. and Primary/Alt. Comm.

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for the safe evacuation from the PRTF including care and treatment needs of residents, staff responsibilities, transportation, identification of evacuation locations and primary and alternate means of communication. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 022 Policies/Procedures for Sheltering in Place

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for a means to shelter in place for residents, staff and volunteers who remain in the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 023 Policies/Procedures for Medical Documentation

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for a system of medical documentation which preserves patient information, protects confidentiality and secures and maintains availability of records for the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 024 Policies/Procedures-Volunteers and Staffing

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for the use of volunteers in an emergency for the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 025 Arrangement with Other Facilities

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures based on the emergency plan, risk assessment and communication plan. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 026 Roles Under a Waiver Declared by Secretary

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for the role of the PRTF under a waiver declared by the Secretary in the provision of care and treatment at an alternate care site identified by emergency officials. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 029 Development of Communication Plan

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws for the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 030 Names and Contact Information

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness communication plan for the PRTF that contains names and contact information for staff, entities providing services under arrangement, resident physicians, other facilities and volunteers. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 031 Emergency Officials Contact Information

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness communication plan for the PRTF that contains names and contact information for Federal, State, tribal, regional and local emergency preparedness staff and other sources of assistance. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 032 Primary/Alternate Means for Communication

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness communication plan for the PRTF that included a primary and alternate means for communicating with PRTF staff, Federal, State tribal, regional and local management agencies. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 033 Methods for Sharing Information

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness communication plan for the PRTF that included a method for sharing information and medical documentation for residents under the PRTF's care as needed with other health care providers to maintain the continuity of care. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 034 Information on Occupancy/Needs

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness communication plan for the PRTF that included a means for providing information about the PRTF's occupancy, needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center or designee. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 036 EP Training and Testing

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness training and testing program for the PRTF that is based on the emergency plan, risk assessment and communication plan. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 037 EP Training Program

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness training program for the PRTF that provided initial training in emergency preparedness policies and procedures to all new and existing staff provide emergency preparedness training every two (2) years, demonstrate staff knowledge and maintain documentation of the training. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 039 EP Testing Requirements

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness testing program for the PRTF that conducted testing exercises twice a year. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 042 Integrated EP Program

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to meet all requirements to unify and integrate with the hospital healthcare system Emergency Preparedness Plan (EPP). This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility EPP revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.