Deficiency in Emergency Preparedness Plan
Penalty
Summary
The Healthcare Center at White Horse Village was found to have deficiencies in its Emergency Preparedness Plan during a survey conducted on January 13, 2025. The facility failed to ensure that its policies and procedures adequately addressed the resident population, including persons at-risk, the type of services the facility could provide in an emergency, and the continuity of operations, including delegations of authority and succession plans. This deficiency was identified through a document review and confirmed during an exit interview with the Administrator and the Maintenance Director. The survey revealed that the facility's Emergency Preparedness Plan did not include the necessary documentation to address these critical areas, affecting the entire facility. The lack of documentation was confirmed during the exit interview, indicating a failure to comply with the requirements set forth in 42 CFR 483.73(a)(3). This deficiency has the potential for minimal harm, as it pertains to the facility's ability to effectively manage emergencies and ensure the safety and well-being of its residents.
Plan Of Correction
Facility established policy to define the patient population served, patients at risk and the types of services that the community can provide in an emergency to ensure continuity. The Senior Director of Property and Facilities will ensure the Emergency Operations Manual and related policies are reviewed on an annual basis. Results of review will be submitted by The Senior Director of Property and Facilities to the Quality Assurance and Performance Improvement Committee on an annual basis.