Autumn Springs Health Care Services, Inc

The agency failed to ensure an emergency preparedness plan was based on a community based risk assessment that was updated annually.

The agency failed to ensure the emergency preparedness plan included documentation on how the agency would participate with state, local, and tribal authorities or any documentation of an attempt to contact these authorities.

The agency failed to ensure the emergency preparedness plan included a procedure to inform local and state officials of staff and patients the agency is unable to contact during a disaster.

The agency failed to ensure a communication plan was in place that included emergency officials contact information.

The agency failed to ensure all staff were trained in the emergency preparedness at least annually and failed to ensure the agency participated in a community based full scale drill and completed a second full scale drill or table top drill annually.