Failure to Maintain Emergency Preparedness Documentation
Penalty
Summary
The facility failed to maintain proper emergency preparedness guidelines as required by regulatory standards. During a document review conducted on January 22, 2025, it was discovered that the facility did not have records of conducting an annual full-scale exercise, testing, evaluating, and performing a tabletop exercise for their emergency preparedness plan. This lack of documentation indicates that the facility did not adhere to the necessary protocols to ensure readiness in the event of an emergency. The deficiency was confirmed through an interview with the maintenance supervisor on the same day. The supervisor acknowledged the absence of documentation, which further substantiates the facility's failure to comply with the emergency preparedness requirements. This oversight suggests a significant gap in the facility's ability to effectively respond to potential emergencies, as they have not demonstrated the necessary preparedness through documented exercises and evaluations. The lack of a tabletop exercise, in particular, highlights a critical area where the facility did not meet the expected standards. Tabletop exercises are essential for facilitating group discussions and problem-solving in a simulated emergency scenario, which helps in identifying potential weaknesses in the emergency plan. The absence of such exercises means that the facility has not fully tested its emergency procedures, potentially compromising the safety and well-being of its residents and staff.
Plan Of Correction
The Emergency Preparedness Plan (EPP) was reviewed and updated as necessary. The Emergency Preparedness Plan is to be reviewed and updated at least annually based on the most recent documented, facility-based and community-based risk assessment using an all-hazards approach. NHA/designee to complete annual full-scale exercise/table-top exercise by 21MAR2025. NHA/designee to educate all staff by 21MAR2025 on the EPP to ensure a comprehensive understanding of policies and procedures to ensure staff readiness. RVPO/designee to educate NHA by 21MAR2025 on the requirements of Emergency Preparedness Plan Guidelines. To prevent this from recurring, RVPO will complete annual audits on facility EPP to ensure current updated version. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendation.