Deficiency in Emergency Preparedness Plan Documentation
Penalty
Summary
The facility was found to be deficient in its emergency preparedness plan, specifically lacking policy and procedure documentation regarding the role of the Ambulatory Surgical Center under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficiency affects the entire facility as it pertains to the provision of care and treatment at an alternate care site identified by emergency management officials. During a document review on January 21, 2025, it was revealed that the facility could not provide the necessary documentation for their Emergency Preparedness Plan 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.
Plan Of Correction
The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulation, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. The Emergency Prepared Plan policy and procedure documentation concerning the Roles under a Waiver Declared by Secretary was located and placed in the Emergency Prepared Plan. The Maintenance Director was in-serviced on ensuring that the Emergency Prepared Plan is complete and updated. The Maintenance Director will monitor and review this plan of correction at the monthly Quality Assurance Performance Improvement meeting to ensure compliance is maintained.