Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
York Nursing And Rehabilitation Center was found to have a deficiency in its emergency preparedness communication plan during a survey conducted on January 30, 2025. The survey revealed that the facility's plan did not include a means of providing information about the facility's needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or a designee. This deficiency affects the entire facility and was confirmed during an exit interview with the Administrator and the Maintenance Director. The deficiency was identified through a document review conducted at 8:30 a.m. on the day of the survey. The absence of this critical information in the emergency preparedness communication plan indicates a gap in the facility's ability to effectively communicate its needs and capabilities during an emergency. The lack of documentation was acknowledged by the facility's leadership during the exit interview, confirming the surveyors' findings.
Plan Of Correction
Step 1 The facility reviewed and revised the Emergency Preparedness Manual to include a Policy detailing the means of providing information about the facility's needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. Step 2 NHA educated on the requirement to include the facility's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee in its emergency communication plan. Step 3 NHA/ Designee will review the emergency preparedness manual annually to ensure that the emergency communication plan complies with federal and state laws.