Emergency Preparedness Plan Lacks Key Components
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included comprehensive policies and procedures addressing the resident population, particularly persons at-risk, the types of services the facility could provide during an emergency, and the continuity of operations, including delegations of authority and succession plans. This deficiency was identified during a document review conducted on January 23, 2025, at 8:30 a.m., which revealed that the plan did not adequately cover these critical areas. During an exit interview with the Administrator and Maintenance Director on the same day at 11:45 a.m., it was confirmed that there was a lack of documentation supporting the inclusion of these necessary components in the Emergency Preparedness Plan. This oversight affects the entire facility, as it leaves the facility unprepared to effectively manage emergencies, particularly concerning the care and safety of at-risk residents.
Plan Of Correction
1. Policy on person at risk was reviewed and education done with staff. 2. Policy available in Emergency Preparedness binder.