Every finding on record at Soulistic Medical Institute

Based on review of facility policies and procedures, review of facility documentation and interview, it has been determined the facility failed to develop an emergency preparedness plan that includes strategies for addressing emergency events identified by the facility based risk assessment. --- Findings include: Facility Policy # 604 titled, "...Disaster Preparedness...." did not reveal written process or procedure to address strategies for addressing emergency events identified by the facility based risk assessment. A review was conducted of all materials presented related to the emergency preparedness communication. Materials did not reveal written process or procedure address strategies for addressing emergency events identified by the facility based risk assessment. In an interview conducted with Employee #2, Employee #2 confirmed that copies of all materials related to emergency preparedness had been provided. Per employee #2 the emergency plan and procedures are currently under review and will be updated to include written policy and procedure to formalize plan to address strategies for addressing emergency events identified by the facility based risk assessment.

Based on review of facility policies and procedures, review of facility documentation and interview, it has been determined the facility failed to develop a policy regarding the use of volunteers during an emergency. Failure to develop a policy regarding the use of volunteers during an emergency event can result in being unprepared for employees who wish to volunteer during a mass casualty event or for the need to accept volunteer staff during a mass casualty event. --- Findings include: Facility Policy # 604 titled, "...Disaster Preparedness...." did not reveal written process or procedure address use of volunteers or other staffing strategy to address surge needs during an emergency. A review was conducted of all materials presented related to the emergency preparedness communication. Materials did not reveal written process or procedure address use of volunteers or other staffing strategy to address surge needs during an emergency. In an interview conducted with Employee #2, Employee #2 confirmed that copies of all materials related to emergency preparedness had been provided. Per employee #2 the emergency plan and procedures are currently under review and will be updated to include written policy and procedure to formalize plan on the use of volunteers or other staffing strategy to address surge needs during an emergency.