Deficiency in Emergency Preparedness Plan
Penalty
Summary
The facility was found to be deficient in developing an Emergency Preparedness Plan that included the required names and contact information. During a document review on January 21, 2025, it was revealed that the facility's plan did not contain or reference the necessary contact information for staff, entities providing services under arrangement, patients' physicians, other facilities, and volunteers. This omission was identified as a failure to comply with the regulatory requirements for emergency preparedness communication plans. An exit interview with the Executive Director of Construction and Ancillary Services confirmed that while a contact information template was included in the Emergency Preparedness Plan, it lacked the specific names and contact information of facility-based individuals. This deficiency indicates that the facility did not meet the mandated standards for maintaining an up-to-date and comprehensive communication plan, which is essential for effective emergency preparedness.
Plan Of Correction
1) Updated communication plan and list completed by facility. 2) ED of construction to inservice supervisor of plant OPS on policy and procedure of keeping communications plan and list up to date. 3) ED of construction or delegate to complete audits 3x per week x 4 weeks to ensure communication plan and list are completed in accordance with policies and procedures. Audits findings will be submitted to QAPI committee monthly for further reviews and recommendations as needed. Further audits frequently will be determined based on the outcome of the survey.