Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required two exercises to test the emergency preparedness plan, which affected the entire facility. This deficiency was identified during a document review conducted on January 21, 2025, at 8:45 a.m. The review revealed that the facility did not perform the necessary exercises within the previous 12 months, as mandated by the regulations. The deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services on the same day at 1:15 p.m. During this interview, it was acknowledged that the documentation supporting the completion of the required exercises was not available. This lack of documentation indicates that the facility did not adhere to the regulatory requirements for emergency preparedness testing. The absence of these exercises suggests a failure in maintaining compliance with the emergency preparedness standards set forth for long-term care facilities. The facility's inability to provide evidence of conducting these exercises highlights a significant oversight in their emergency preparedness protocols.
Plan Of Correction
1) Emergency prep exercise will be completed. 2) ED of construction to Inservice Supervisor of Plant Operations on policy and procedure for ensuring proper requirements are met. 3) Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure. Audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.