Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness communication plan that complies with federal, state, and local laws. This deficiency was identified during a review of the facility's Emergency Preparedness (EP) Plan. On February 6, 2025, at 9:00 a.m., an interview and documentation review revealed that the EP Plan lacked a communication plan that met the required legal standards. This finding was confirmed during an interview with the Facility Administrator and Maintenance Director later that day at 1:00 p.m., who acknowledged the absence of a compliant communication plan in the EP Plan.
Plan Of Correction
Facility emergency preparedness plan will be updated to include communication plan that complies with local, state and federal laws 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.