Emergency Preparedness Plan Lacks Required Contact Information
Summary
The facility failed to ensure that its Emergency Preparedness Plan included the necessary contact information for required emergency officials. During a document review conducted on January 21, 2025, it was discovered that the plan lacked contact information for the State Licensing and Certification Agency and the Office of the State Long-Term Care Ombudsman. This omission affects the entire facility, as these contacts are crucial for effective emergency preparedness and response. An exit interview with the Executive Director of Construction and Ancillary Services confirmed the deficiency. The interview, held on the same day as the document review, further verified that the facility had not developed an Emergency Preparedness Plan that included the required contact information for the specified emergency officials. This oversight indicates a failure to comply with the regulatory requirements for maintaining an updated and comprehensive emergency communication plan.
Plan Of Correction
1) Emergency list has been updated. 2) ED of construction to inservice supervisor of Plant Operations on policy and procedure on emergency contact information. 3) Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to ensure document is completed in accordance with policy and procedure.
Penalty
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