Failure to Establish Emergency Arrangements with Other Facilities
Penalty
Summary
The facility was found deficient in its emergency preparedness policies and procedures, specifically in the development of arrangements with other facilities and providers. During a documentation review, it was revealed that the facility failed to establish necessary agreements to ensure the continuity of services to patients in the event of limitations or cessation of operations. This deficiency affects the entire component of the facility's emergency preparedness plan. An exit interview with the Assistant Administrator and the Maintenance Director confirmed the lack of arrangements with other facilities. This oversight indicates a failure to comply with the regulatory requirement to maintain continuity of care for patients during emergencies, as outlined in the relevant sections of the federal regulations. The deficiency was identified during a survey conducted on December 23, 2024.
Plan Of Correction
Emergency preparedness plan has been reviewed and updated to include facility has made arrangements with other facilities and providers to receive residents in event of an emergency. NPE/designee will re-educate maintenance staff on timely updates for policies and procedures relating to arrangements for residents in the event of an emergency. NHA/designee will complete weekly audits to ensure EPP manual is updated and facility has made arrangements with other facilities and providers to receive residents in event of an emergency. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.