Failure to Conduct Required Emergency Plan Exercise
Penalty
Summary
The facility failed to conduct the required annual full-scale exercise or an accepted substitution for testing its emergency plan. This deficiency was identified during a document review conducted on January 30, 2025, at 8:30 a.m. The review revealed that the facility did not perform a full-scale exercise within the previous 12 months, which is a requirement under the emergency preparedness regulations. The absence of documentation confirming the completion of the annual full-scale exercise was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m. This lack of documentation indicates that the facility did not meet the regulatory requirements for emergency preparedness testing. The deficiency affects the entire facility, as the emergency plan's effectiveness could not be adequately tested and evaluated without the required exercise. The failure to conduct the exercise or provide an acceptable substitution means that the facility did not comply with the mandated emergency preparedness protocols.
Plan Of Correction
E0039 Step 1 A full-scale disaster drill was completed on 1/10/2025. Evidence and signed documents of the drill were added to the emergency preparedness binder. Step 2 NHA educated on the requirement to complete full-scale disaster drills annually and to maintain documentation of the drill in the emergency preparedness binder. Step 3 NHA/ Designee will review the emergency preparedness manual annually to ensure a full-scale disaster drill was completed within the last 12 months.