Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to maintain proper emergency preparedness guidelines as required by regulations. During a document review conducted on January 15, 2025, it was discovered that the facility did not have records indicating that a full-scale exercise, test, and evaluation of the emergency preparedness plan had been performed within the previous year. This lack of documentation suggests that the facility did not conduct the necessary exercises to test their emergency plan, which is a critical component of ensuring readiness for potential emergencies. The deficiency was confirmed during an interview with the maintenance supervisor on the same day. The supervisor acknowledged the absence of documentation, which further substantiates the facility's failure to comply with the regulatory requirements for emergency preparedness. This oversight indicates a lapse in the facility's adherence to mandated protocols designed to ensure the safety and well-being of its residents and staff in the event of an emergency. The regulations require that long-term care facilities conduct at least two exercises per year to test their emergency plans, including a full-scale community-based exercise or an individual facility-based functional exercise. The facility's inability to provide evidence of such exercises being conducted within the specified timeframe highlights a significant gap in their emergency preparedness efforts.
Plan Of Correction
1. Nursing home administrator/designee immediately scheduled full scale exercise with outside community resources to be completed. 2. Regional Vice President of operations educated nursing home administrator on E0039 and the importance of yearly exercises to test the emergency plans. 3. Nursing Home Administrator will verify continued compliance with the EPP/tabletop exercises.