Deficiency in Emergency Preparedness Plan
Penalty
Summary
The facility was found deficient in its emergency preparedness plan due to the absence of policies and procedures addressing the use of volunteers and other emergency staffing strategies during an emergency. Specifically, the plan lacked documentation on the process and role for integrating State and Federally designated health care professionals to address surge needs during an emergency. This deficiency was identified during a document review conducted on January 13, 2025, at 8:00 a.m. During an exit interview with the Administrator and the Maintenance Director later that morning, the lack of documentation was confirmed. The deficiency affects the entire facility, as the emergency preparedness plan is a critical component in ensuring adequate staffing and resource allocation during emergencies. The absence of these policies and procedures indicates a gap in the facility's ability to effectively manage and respond to emergency situations.
Plan Of Correction
Facility established policy for the use of volunteers in an emergency or other staffing strategies. 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.