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 means of providing information about the Ambulatory Surgical Center's (ASC) needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. 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 on the same day at 10:30 a.m., it was confirmed that the facility lacked the necessary documentation in its emergency preparedness communication plan. This oversight affects the entire facility, as it fails to comply with the requirement to maintain a comprehensive communication plan that includes the ASC's needs and capabilities.
Plan Of Correction
Facility established policy to provide information about the community's occupancy, needs and its ability to provide assistance, to authorities having jurisdiction. 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.
Penalty
Surveyors found that the facility’s emergency preparedness communication plan did not include required information on how to report facility occupancy through the Healthcare Facility Reporting System. During record review and a concurrent interview, the Administrator acknowledged that the plan lacked a specified means of providing occupancy information to the incident commander, resulting in a facility-wide deficiency in the communication plan.
The facility's emergency preparedness communication plan lacked a means of providing information about the ASC's needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This deficiency was confirmed during an exit interview with the Maintenance Director, affecting the entire facility.
York Nursing And Rehabilitation Center's emergency preparedness communication plan lacked a means to provide information about the facility's needs and ability to assist to authorities, affecting the entire facility. This deficiency was confirmed during a survey and acknowledged by the facility's leadership.
The facility's emergency preparedness communication plan was found lacking as it did not include a method for providing information about the facility's needs and its ability to provide assistance to the authority having jurisdiction or the Incident Command Center. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
Emergency Preparedness Communication Plan Lacked Required Occupancy Reporting Information
Penalty
Summary
Surveyors identified a deficiency in the facility’s emergency preparedness communication plan related to the requirement to provide information on occupancy. During record review at 2:00 PM, the surveyor determined that the written communication plan did not include any information on the Healthcare Facility Reporting System, which is the mechanism used to report the facility’s occupancy. The plan therefore lacked a specified means of providing information about the facility’s occupancy as required by the applicable emergency preparedness regulations. In a concurrent staff interview, the Administrator acknowledged that the communication plan did not contain the required information about occupancy reporting. The Administrator confirmed the absence of this information in the plan. The deficiency was determined to affect the entire facility, as the missing occupancy reporting component related to communication of resident needs to the incident commander during an emergency.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with E0034 and assure continued compliance, the following plan has been put in place. E0034 ~ Communication Plan (HFRS) Immediate Correction: The Emergency Preparedness Communication Plan was updated to include a dedicated section for the Health Facility Reporting System (HFRS), explicitly outlining requirements for reporting emergency status, planning, and operations. Identification of Others: All residents have the potential to be affected by communication failures. The Administrator audited the entire Emergency Plan to ensure HFRS Superuser access, login procedures, and technical support contacts (850-412-4303/4304) were included. Systemic Changes: Administrative and nursing leadership were trained on the AHCA HFRS manual and internal procedures for updating census and .utility data. A screenshot of the facility's HFRS registration was added as an appendix to the Plan. Monitoring (QA): The Safety Committee will review the plan semi-annually to ensure protocols remain current. Results will be documented in the QAPI meeting minutes.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility's emergency preparedness communication plan was found to be deficient as it did not include a means of providing information about the Ambulatory Surgical Center's (ASC) needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This deficiency was identified during a document review conducted on May 1, 2025, at 8:15 a.m. During an exit interview with the Maintenance Director on the same day at 10:30 a.m., it was confirmed that the documentation necessary to meet this requirement was lacking. This oversight affects the entire facility, as the communication plan is a critical component of emergency preparedness and response.
Plan Of Correction
The facility's emergency preparedness communication plan will include a developed means of providing information about the LTC needs and its ability to help the authority having jurisdiction, the Incident Command Center, or designee. The facility will update the EP Book and add it to QAPI for review.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
York Nursing And Rehabilitation Center was found to have a deficiency in its emergency preparedness communication plan during a survey conducted on January 30, 2025. The survey revealed that the facility's plan did not include a means of providing information about the facility's needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or a designee. This deficiency affects the entire facility and was confirmed during an exit interview with the Administrator and the Maintenance Director. The deficiency was identified through a document review conducted at 8:30 a.m. on the day of the survey. The absence of this critical information in the emergency preparedness communication plan indicates a gap in the facility's ability to effectively communicate its needs and capabilities during an emergency. The lack of documentation was acknowledged by the facility's leadership during the exit interview, confirming the surveyors' findings.
Plan Of Correction
Step 1 The facility reviewed and revised the Emergency Preparedness Manual to include a Policy detailing the means of providing information about the facility's needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. Step 2 NHA educated on the requirement to include the facility's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee in its emergency communication plan. Step 3 NHA/ Designee will review the emergency preparedness manual annually to ensure that the emergency communication plan complies with federal and state laws.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility was found to be deficient in its emergency preparedness communication plan. During a document review on January 23, 2025, it was discovered that the plan did not include a method for providing information about the facility's needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or a designee. This omission affects the entire facility, as it lacks a crucial component of emergency preparedness. An exit interview with the Administrator and Maintenance Director on the same day confirmed the absence of this documentation. The deficiency highlights a gap in the facility's ability to communicate effectively during emergencies, which is a requirement under federal regulations. The lack of a comprehensive communication plan could potentially hinder the facility's response in emergency situations.
Plan Of Correction
1. At risk resident list with mobility status was available as of 1-22-2025 and failed to give to inspector at inspection. 2. NHA will ensure the list is maintained in the emergency prepared book.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.