Emergency Preparedness Plan Lacks Key Components
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included comprehensive policies and procedures addressing the patient population, specifically focusing on persons at-risk. During a document review conducted on February 6, 2025, it was revealed that the plan lacked necessary details regarding the types of services the facility could provide in an emergency and the continuity of operations, including delegations of authority and succession plans. An exit interview with the Facility Administrator and Maintenance Director confirmed the absence of documentation addressing these critical areas. This deficiency affects the entire facility, as it does not adequately prepare for the needs of its resident population in emergency situations.
Plan Of Correction
Adopted Policy and procedure for addressing patient population, including, but not limited to, persons at risk into facility's emergency preparedness plan by 3/21/2025. A review of policies and procedures will be conducted on an annual basis by the Administrator or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.