Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to meet the emergency preparedness requirements as outlined in the regulations. Specifically, the facility did not conduct the required annual full-scale exercise or an accepted substitution, nor did it conduct the additional exercise or an accepted substitution within the previous 12 months. This deficiency affects the entire facility, indicating a lapse in maintaining readiness for emergency situations. During a document review on December 23, 2024, it was revealed that the facility had not conducted these mandatory exercises. The regulations require that long-term care facilities participate in a full-scale exercise that is community-based annually or conduct an individual, facility-based functional exercise if a community-based exercise is not accessible. Additionally, an extra exercise, such as a mock disaster drill or a tabletop exercise, should be conducted annually. The facility's failure to perform these exercises suggests a significant oversight in adhering to emergency preparedness protocols. The deficiency was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director on the same day. They acknowledged the lack of emergency preparedness exercises, which is a critical component of ensuring the safety and well-being of residents and staff in the event of an actual emergency. This oversight highlights the need for the facility to reassess its emergency preparedness strategies and ensure compliance with federal regulations.
Plan Of Correction
Emergency preparedness plan has been reviewed and updated to include an annual full scale/table to review exercise. Maintenance Dir/designee will re-educate maintenance staff on timely updates for policies and procedures relating to annual full scale/table to review exercise. NHA/designee will complete weekly audits x1 and monthly x2 to ensure annual full scale/table to review exercise. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.