Lucent Health Group

The agency failed to complete an internal review of its emergency preparedness and response plan at least annually for calendar year 2017 to evaluate its effectiveness and to update the plan as needed.

The agency's written emergency preparedness and response plan failed to include a risk assessment which identified the disasters from natural and man-made causes which were most likely to occur in the agency's service areas.

The facility failed to provide documentation of agency participation in a) a annual full-scale community-based or individual facility-based exercise; b) a second tabletop exercise for the year; and c) an analysis of the facility's response phase, with review and any updates of the emergency…

The agency failed to provide a copy of the agency's transfer/ discharge policy to 1 (Patient 1) of 1 patient within 4 business days of the initial evaluation visit in accordance with the January, 2018 Federal Conditions of Participation (CoPs).

The agency failed to advise 1 (Patient 1) of 1 patient of the names, addresses, and telephone numbers of Federally-funded and state-funded entities that service the area where the patient resides in accordance with the January, 2018 Federal Conditions of Participation (CoPs).