Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to meet the emergency preparedness testing requirements as outlined in §483.73(d)(2). Specifically, the facility did not conduct one of the two required annual exercises to test its emergency preparedness plan. This deficiency was identified during a document review conducted on November 20, 2024, which revealed that within the previous 12 months, the facility had only performed a full-scale exercise and did not conduct the additional required exercise. During an exit interview on the same day, the Administrator and the Maintenance Director confirmed the lack of an additional exercise. This oversight affected the entire facility, as the emergency preparedness plan was not fully tested as required by the regulations. The absence of the additional exercise meant that the facility did not fully comply with the regulatory requirements for emergency preparedness testing. A follow-up onsite revisit conducted on January 8, 2025, confirmed that the deficiency had not been addressed. The document review during this revisit showed that the facility still had not performed the additional required exercise within the previous 12 months. The Administrator and the Regional Maintenance Director confirmed this ongoing deficiency during an exit interview on the same day.
Plan Of Correction
1. Deficiency: Based on document review and interview, it was determined that the facility failed to conduct one of the two required annual exercises to test the facility's emergency preparedness plan, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed that within the previous 12 months, the facility performed only a full-scale exercise and did not perform the additional required exercise to test the emergency preparedness plan. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of the additional exercise. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected if the facility's emergency preparedness plan is not properly tested through regular exercises. 2. Corrective Action: The facility will conduct the additional required annual exercise, ensuring that both a full-scale exercise and a tabletop exercise (or another approved exercise) are completed within the required time frame to properly test the emergency preparedness plan. A schedule will be developed to ensure that future exercises are performed on time and documented accordingly. 3. Monitoring: The facility will track the completion of required exercises and ensure they are conducted annually as per regulations. Documentation of each exercise, including participant involvement and outcomes, will be reviewed by the Quality Assessment and Assurance Committee. 4. Timeline: The additional required exercise will be completed by 01/28/25. Future exercises will be scheduled and conducted annually, with documentation reviewed for compliance.