Emergency Preparedness Plan Lacks Volunteer and Staffing Policies
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a review of its Disaster Manual Disaster Plan. The plan, which was last reviewed on 10/16/24, did not include policies and procedures for the use of volunteers and other staffing strategies. This deficiency affected all resident use floors, including three resident units, the administration area, and the basement. During an interview, the Administrator confirmed that the Disaster Manual Disaster Plan was the current emergency preparedness plan in use since the facility's inception in 2024. The Administrator also acknowledged that an updated Emergency Preparedness Plan was being developed but had not yet been implemented.
Plan Of Correction
Plan of Correction: Approved December 29, 2024 1. Administrator completed review of the current EPP on 12/29/2024 and updated EPP to include policy and procedure for Volunteer and procedure for staffing procedures on 12/29/2024. 2. All Residents are at risk for deficient practice for not having policy procedure on volunteer and staffing procedures addressed in EPP. 3. All staff were trained on the emergency preparedness plan which included policy and procedure on volunteers and staffing procedure by RN Educator. Education was completed for all staff on 1/24/2024. 4. The EPP will be reviewed quarterly in the QAPI meeting to ensure updated EPP is reviewed and updated on all policies required to be included in EPP including Volunteers and staffing strategies. Any deficient practices will be corrected and further reviewed at QAPI Meeting. Person Responsible: Administrator
Penalty
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