Lack of Post-Disaster Analysis Documentation
Penalty
Summary
The facility failed to provide documentation of post-disaster analysis, including potential areas of improvement and revision of the Emergency Preparedness Program (EP). This deficiency was identified during a review of disaster drills conducted by the facility. Specifically, one of the required two drills did not include an After Action Report (AAR), which is essential for evaluating the facility's response to emergencies and identifying areas for improvement. During the review, it was noted that the absence of an AAR could leave the facility unprepared for unexpected situations that might arise during an actual emergency. The AAR is a critical component of the emergency preparedness process, as it allows the facility to document its response to drills and real events, analyze the effectiveness of its emergency plan, and make necessary revisions to address any shortcomings. The deficiency was confirmed through an interview with the Administrator, who acknowledged the omission and indicated that future drills would include an AAR. However, the lack of documentation for the drill in question highlights a gap in the facility's emergency preparedness efforts, which could potentially impact its ability to respond effectively to real emergencies.
Plan Of Correction
3/12/25 1. Drills were updated to meet the requirements of E039. 2. Audit of E tags was conducted, and any incorrect findings were corrected. 3. Education provided for E39. 4. Audit for compliance for E39 will be completed by administrator or designee monthly and report to QAPI for one quarter.