Deficiency in Emergency Preparedness Plan
Penalty
Summary
The facility's Emergency Preparedness (EP) Plan was found to be deficient during a review conducted on February 6, 2025. The review revealed that the EP Plan did not include updated and accurate names and contact information for the staff and residents' physicians. This omission was identified during an interview and documentation review at 9:15 a.m. The deficiency was confirmed in a subsequent interview with the Facility Administrator and Maintenance Director at 1:00 p.m. on the same day. The lack of updated contact information in the EP Plan indicates a failure to comply with the requirement to maintain a comprehensive communication plan, which is essential for effective emergency preparedness.
Plan Of Correction
Facility emergency preparedness plan will be updated by 3/21/2025 for accurate names and contact information for staff and resident physicians. A review of the staff and resident physicians will be conducted monthly by the Maintenance director or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.