Emergency Preparedness Plan Lacks Key Components
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included comprehensive policies and procedures addressing the patient population, specifically focusing on persons at-risk. The plan was also required to outline the types of services the facility could provide during an emergency and ensure continuity of operations, including delegations of authority and succession plans. However, upon document review, it was found that the plan did not adequately address these critical components, particularly the aspect concerning persons at-risk. During an exit interview with the Assistant Administrator and the Maintenance Director, it was confirmed that there was a lack of documentation supporting the inclusion of these necessary elements in the Emergency Preparedness Plan. This deficiency affects the entire facility, as the absence of these policies and procedures could potentially impact the facility's ability to effectively manage emergencies and ensure the safety and well-being of its residents.
Plan Of Correction
Emergency preparedness plan has been reviewed and updated to include policies and procedures for person at risk has been reviewed and updated in the manual. NPE/designee will re-educate maintenance staff on timely updates and to keep the EPP book in the maintenance office. NHA/designee will complete weekly 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.