Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility was found to be deficient in its emergency preparedness communication plan. During a document review on January 23, 2025, it was discovered that the plan did not include a method for providing information about the facility's needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or a designee. This omission affects the entire facility, as it lacks a crucial component of emergency preparedness. An exit interview with the Administrator and Maintenance Director on the same day confirmed the absence of this documentation. The deficiency highlights a gap in the facility's ability to communicate effectively during emergencies, which is a requirement under federal regulations. The lack of a comprehensive communication plan could potentially hinder the facility's response in emergency situations.
Plan Of Correction
1. At risk resident list with mobility status was available as of 1-22-2025 and failed to give to inspector at inspection. 2. NHA will ensure the list is maintained in the emergency prepared book.