Based on interview, review of facility policies and procedures and review of facility documentation, it has been determined the facility failed to develop policies and procedures addressing 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. This deficient practice has the potential to jeopardize patient safety and negatively impact the agency's ability to respond to patient needs. --- Findings include:Review of Agency Policy 6-037.1 titled, "Emergency Management Plan" revealed, ".... Strategies should be developed based on events identified in during the development of the HVA such as staffing strategy for staff shortages and a surge capacity strategy...."Review of Facility documentation failed to reveal staffing strategy plan for staff shortages and a surge capacity strategy in the eventof an emergency.Administrator verified detailed emergency staffing strategy plan could not be provided.
Every finding on record at Jentilly Healthcare LLC
Casa Grande, Arizona · CCN 031678
1 finding across 1 survey, in the inspector's own words.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Survey of March 27, 2025
1 finding← Back to the Jentilly Healthcare LLC record
Federal survey findings only. State licensure findings for hospices are not shown.
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