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E0004
C

Failure to Annually Update Emergency Preparedness Plan

Pittsburgh, Pennsylvania Survey Completed on 02-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with the requirement to review and update their Emergency Preparedness (EP) Plan at least annually. During a review conducted on February 6, 2025, it was discovered that the EP Plan had not been updated in over 12 months. This finding was based on both an interview and documentation review conducted at 8:05 a.m. Further confirmation of this deficiency was obtained during an interview with the Facility Administrator and Maintenance Director at 1:00 p.m. on the same day. Both individuals acknowledged that the EP Plan had not been reviewed and updated as required on an annual basis, leading to the facility's non-compliance with federal regulations.

Plan Of Correction

Emergency preparation will be updated by 3/21/2025. An annual review will be audited by the Maintenance Director or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.

See complete original report
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