Failure to Document Emergency Preparedness Exercises
Penalty
Summary
Edinboro Manor was found to be non-compliant with the emergency preparedness requirements as outlined in 42 CFR 483.73. The facility failed to conduct and document the necessary exercises to test its emergency preparedness plan. Specifically, the facility did not have documentation to verify that an annual tabletop exercise had been conducted. This deficiency was identified during a document review on February 4, 2025. The survey revealed that the facility also lacked documentation for an annual full-scale exercise. These exercises are crucial for testing and evaluating the facility's emergency preparedness plan, ensuring that staff and systems are ready to respond effectively in the event of an emergency. The absence of such documentation indicates that the facility did not meet the regulatory requirements for emergency preparedness testing. An interview with the maintenance supervisor confirmed the lack of documentation for both the full-scale and tabletop exercises. This confirmation further substantiates the finding that Edinboro Manor did not fulfill its obligations to conduct and document these critical emergency preparedness activities, as required by federal regulations.
Plan Of Correction
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Edinboro Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Edinboro Manor's credible allegation of compliance. The facility will ensure that there is at least one tabletop exercise, and one full-scale exercise completed annually. The facility recently had a change in Administrators effective 12/30/2024. During the Life Safety Survey, proof of an Emergency Preparedness Tabletop discussion could not be found during the inspection. After exit, the facility located documentation of an Emergency Preparedness Tabletop discussion that occurred on 03/21/2024 by past administration. Sign-in sheet and documentation will be provided with this Plan of Correction. The facility will conduct a "full-scale exercise" by 03/13/2025. The full-scale exercise will be reviewed at the monthly Quality Assurance and Performance improvement meeting.