Lack of Emergency Preparedness Documentation Under Waiver
Penalty
Summary
The facility failed to provide the necessary policy and procedure documentation regarding its role under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficiency was identified during a document review conducted on January 13, 2025, at 8:00 a.m. The review revealed that the facility did not have an Emergency Preparedness Plan that included the required documentation concerning the roles under a waiver declared by the Secretary. An exit interview with the Administrator and the Maintenance Director confirmed the absence of this critical documentation. The lack of documentation affects the entire facility, as it pertains to the provision of care and treatment at an alternate care site identified by emergency management officials. This deficiency highlights a significant gap in the facility's emergency preparedness policies and procedures.
Plan Of Correction
Facility established policy to establish roles for providing care during emergencies under blanket or specific $1135 waivers. 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.