Failure to Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to provide a written Emergency Preparedness Plan (EP) that includes an updated facility-based and community-based risk assessment. This deficiency was identified during a document review and interview conducted on February 6, 2025. The review revealed that the facility had not updated its risk assessment using an all-hazards approach, which is a requirement for maintaining an effective emergency preparedness plan. During the interview with the Facility Administrator and Maintenance Director, it was confirmed that the facility's EP plan was deficient in this regard. The lack of an updated risk assessment indicates that the facility did not adequately prepare for potential emergency events, as required by the regulations. This oversight could potentially impact the facility's ability to respond effectively to emergencies.
Plan Of Correction
Facility based/community-based risk assessment will be completed by 3/21/2025. An annual review of the risk assessment will be conducted by the Administrator or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.