Deficiency in Emergency Preparedness Plan Review
Penalty
Summary
Chapel Manor was found to have a deficiency related to its Emergency Preparedness Plan during an Emergency Preparedness Survey conducted on December 23, 2024. The survey revealed that the facility failed to review and update its Emergency Preparedness Plan at least annually, as required by federal regulations under 42 CFR 483.73(a). This deficiency was identified through a documentation review conducted at 8:30 a.m. on the day of the survey. An exit interview with the Assistant Administrator and the Maintenance Director confirmed that the Emergency Preparedness Plan had not been reviewed and updated as required. This oversight affects the entire facility, as the plan is a critical component of the facility's ability to respond effectively to emergencies. The lack of annual review and updates to the plan constitutes a failure to comply with the necessary emergency preparedness requirements, which are designed to ensure the safety and well-being of all residents and staff in the facility.
Plan Of Correction
Emergency preparedness plan has been reviewed and updated for 2024-2025. Maintenance Dir/designee will re-educate maintenance staff on timely updates and to keep the EPP book in one location. NHA/designee will complete quarterly audits to ensure EPP manual is updated and its proper location. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.