Deficiency in Emergency Preparedness Planning
Penalty
Summary
The facility was found deficient in its emergency preparedness planning, specifically in failing to develop and document policies and procedures concerning its role under a waiver declared by the Secretary of the Department of Health, in accordance with section 1135 of the Act. This deficiency was identified during a document review conducted on December 18, 2024, which revealed that the facility did not have an Emergency Preparedness Plan that included the necessary provisions for care and treatment at an alternate care site as identified by emergency management officials. During the exit interview with the Administrator, Administrator in training, and Maintenance Director, it was confirmed that the facility lacked the required documentation. This deficiency affects the entire facility, as it does not have the necessary policies and procedures in place to guide its actions under a waiver declared by the Secretary, potentially impacting its ability to provide care and treatment at alternate care sites during emergencies.
Plan Of Correction
Paperwork has been downloaded regarding the waiver of the Secretary of State regarding section 1135 of the Act. This will be implemented and added to our Emergency Preparedness plan by January 1st, 2025.