Deficiency in Emergency Preparedness Plan at Wyndmoor Hills
Penalty
Summary
Wyndmoor Hills Rehabilitation And Nursing Center was found to have a deficiency related to their Emergency Preparedness (EP) plan during a survey conducted on January 27, 2025. The facility failed to develop and implement policies and procedures that included their role in providing care and treatment at alternate care sites during emergencies, as required under an 1135 waiver declared by the Secretary. This deficiency was identified through a document review and confirmed during an exit interview with the Administrator and Maintenance Director. The survey revealed that the facility's EP plan did not address the facility's responsibilities in the event of an emergency that necessitates care at alternate sites, as identified by emergency management officials. This oversight affects the entire facility, as the EP plan is a critical component in ensuring preparedness and response during emergencies. The absence of these policies and procedures was confirmed during the exit interview, highlighting a gap in the facility's emergency preparedness strategy.
Plan Of Correction
1. Emergency preparedness plan was immediately updated with policy and procedures for 1135 waiver. 2. Emergency preparedness plan was audited to ensure proper compliance. 3. Education provided to ensure proper compliance with this regulation. 4. Emergency preparedness plan will be audited to ensure proper compliance 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.