Deficient Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain an up-to-date communication plan as part of their Emergency Preparedness Program (EP). During a review conducted on February 11, 2025, it was found that the list of staff included individuals who no longer worked at the facility. This deficiency was identified through a record review and interview process, where the Administrator acknowledged that the plan had been reviewed through the Quality Assurance and Performance Improvement (QAPI) process but still required several updates, including current staffing information. The absence of an accurate communication plan, particularly in the context of an emergency, poses a risk to residents as it could lead to a lack of medical and support staffing during a transfer to other facilities. The deficiency highlights the facility's failure to ensure that the communication plan includes the necessary names and contact information of staff and residents' physicians, which is crucial for effective emergency response and resident safety.
Plan Of Correction
1. Name and contact information was updated to reflect current contacts and employees. 2. Audit of E tags was conducted, and any incorrect findings were corrected. 3. Education provided for E030. 4. Audit for compliance for E30 will be completed by administrator or designee monthly and reported to QAPI for one quarter.