Deficiency in Emergency Preparedness Communication Plan
Summary
The facility's emergency preparedness communication plan was found to be deficient as it did not include a method for sharing information and medical documentation for patients with other health care providers. This deficiency was identified during a document review conducted on January 13, 2025, at 8:00 a.m. The absence of this critical component in the communication plan affects the entire facility, as it is essential for maintaining the continuity of care during emergencies. During an exit interview with the Administrator and the Maintenance Director on the same day at 10:30 a.m., it was confirmed that the facility lacked the necessary documentation to support the sharing of patient information and medical documentation. This oversight in the emergency preparedness communication plan indicates a failure to comply with the regulatory requirements, which mandate the inclusion of such methods to ensure effective communication and continuity of care in emergency situations.
Plan Of Correction
The facility established policy to share appropriate information from the facility's emergency plan with residents and their representatives. The Senior Director of Property and Facilities will ensure the Emergency Operations Manual and related policies are reviewed on an annual basis. Results of the review will be submitted by the Senior Director of Property and Facilities to the Quality Assurance and Performance Improvement Committee on an annual basis.
Penalty
The facility's Emergency Preparedness Program failed to include a method for sharing occupancy information with authorities, potentially leaving receiving facilities without necessary information for resident transfers. The EP referenced the ESS website, but the Administrator noted plans to update it to use the 'HFRS' resource.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to provide a method for sharing occupancy information and needs as part of their Emergency Preparedness Program (EP). This deficiency was identified during a record review and interview, where it was found that the facility's EP did not include a clear method for communicating occupancy needs to the authority having jurisdiction. This lack of communication could potentially leave receiving facilities and caregivers without the necessary information for accommodating transferred residents. During the review, it was noted that the facility's EP referenced the Emergency Status System (ESS) and included a link to the ESS website. However, the Administrator acknowledged that they would use the online resource 'HFRS' and update the EP to reflect this new website. This indicates that the current EP did not adequately address the requirement for sharing occupancy information, which is crucial for maintaining continuity of care during transfers or intakes of residents.
Plan Of Correction
3/12/25 1. The link was updated to reflect HFRS instead of the old site ESS. 2. Audit of E tags was conducted, and any incorrect findings were corrected. 3. Education provided for E033. 4. Audit for compliance for E33 will be completed by administrator or designee monthly and report to QAPI for one quarter.
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