Failure to Provide Emergency Preparedness Documentation
Penalty
Summary
The facility failed to provide the necessary policy and procedure documentation concerning its role under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficiency was identified during a document review conducted on November 20, 2024, at 8:00 a.m., where it was found that the facility could not produce the required Emergency Preparedness Plan documentation. This documentation is crucial for outlining the facility's responsibilities in providing care and treatment at an alternate care site as identified by emergency management officials. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day. A follow-up onsite revisit on January 8, 2025, between 12:00 p.m. and 12:30 p.m., revealed that the facility still had not addressed the issue, as the necessary documentation was still unavailable. This was further confirmed in an exit interview with the Administrator and the Regional Maintenance Director at 12:45 p.m. on the same day.
Plan Of Correction
Plan of Correction for TAG E0026 - Scope C: Emergency Preparedness Plan 1. Deficiency: A document review on November 20, 2024, at 8:00 a.m. revealed that the facility could not provide Emergency Preparedness Plan policy and procedure documentation concerning the roles under a waiver declared by the Secretary. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected in the event of an emergency situation where the waiver provisions need to be implemented. 2. Corrective Action: The facility will review and update its Emergency Preparedness Plan to include: - Roles and responsibilities of the facility under a waiver declared by the Secretary, in accordance with Section 1135 of the Act. - Procedures for the provision of care and treatment at an alternate care site identified by emergency management officials, if necessary. 3. Monitoring: The Emergency Preparedness Plan will be reviewed annually to ensure continued compliance with updated policies and procedures. Any necessary updates will be presented to the Quality Assessment and Assurance Committee for review and approval. 4. Timeline: The Emergency Preparedness Plan will be reviewed and updated by 1/28/25, with an annual review thereafter.