Deficiency in Annual Review of Emergency Preparedness Plan
Penalty
Summary
Logan Square Rehabilitation And Healthcare Center was found to have a deficiency related to their Emergency Preparedness Plan during an Emergency Preparedness Survey conducted on January 21, 2025. The survey revealed that the facility failed to ensure that their Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, as required by 42 CFR 483.73(a). This deficiency affects the entire facility, as the plan is crucial for ensuring readiness in the event of an emergency. During the document review, it was noted that there were no signatures provided to confirm the annual review or update of the Emergency Preparedness Plan. This was acknowledged during an exit interview with the Executive Director of Construction and Ancillary Services, indicating a lapse in the facility's compliance with federal regulations. The lack of an updated emergency plan could potentially impact the facility's ability to respond effectively to emergencies, although the report does not specify any immediate consequences or risks.
Plan Of Correction
1) EPP reviewed and signed. 2) ED of construction to Inservice Plant Operations supervisor policy and procedure on how to review and update EPP annually. 3) Supervisor of Plant Operations or Delegate to complete audits 3x per week x 4 weeks to ensure compliance with policy and procedure audits to be submitted to quality assurance performance improvement committee monthly for further review. Further audit frequency will be determined based on the outcome of the previously completed audit findings.