Deficiency in Emergency Preparedness Plan
Penalty
Summary
Cedarwood Rehabilitation and Healthcare Center was found to have deficiencies in its Emergency Preparedness (EP) Plan during a survey conducted on January 14, 2025. The facility failed to include updated and accurate names and contact information for its staff and resident physicians, which is a requirement under 42 CFR 483.73. This deficiency was identified through a review of the facility's EP Plan and confirmed during interviews with the Director of Nursing and the Maintenance Director. The survey revealed that the EP Plan did not meet the necessary standards as it lacked essential contact details, which are crucial for effective communication during emergencies. The absence of this information was confirmed by the facility's leadership, indicating a lapse in maintaining the required documentation for emergency preparedness. This oversight has the potential for minimal harm, as it could impede timely communication and coordination in emergency situations.
Plan Of Correction
1. The facility EP plan has been updated to accurately reflect the proper staff and physician contact information. 2. Maintenance director or designee will verify it is updated if information changes. 3. Nursing home administrator or designee will re-educate the maintenance director on accurately and timely updating the EP plan as contact information changes. 4. Maintenance director or designee will audit the EP plan monthly for the next three months to verify contact information is accurate. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed. Date of compliance will be 2/18/2025.