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NY State Tag
C

Emergency Preparedness Contact Information Not Updated

Pittsford, New York Survey Completed on 02-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with emergency preparedness requirements as identified during an Emergency Preparedness Plan review and Life Safety Code Survey. The deficiency was noted in the facility's failure to update emergency contact information in the New York State Health Commerce System. Specifically, the 24/7 Facility Contact information was last updated in August 2021, the Director of Nursing's information was last updated in June 2023, the Emergency Medical Supplies Receiving Office was last updated in March 2020, and the Office of the Administrator was last updated in August 2021. Additionally, the contact information for the Director of Nursing was outdated, listing an email address for a former employee. During an interview, the Administrator acknowledged that the Director of Nursing's information was not current and stated that they would update it.

Plan Of Correction

Plan of Correction: Approved March 5, 2025 1. Facility emergency contacts list was updated 02/13/2025 on the Health Commerce System. 2. All other facility contact lists were reviewed to ensure they were up to date as well to reflect our current staff. 3. The Contact list will be updated annually by Administrator. All pertinent staff will be educated on the need to ensure this list is always current and up to date. 4. A copy of emergency contact list will be presented to QAPI committee monthly for three months to ensure accuracy. Then the QA committee will determine the needed audit frequency thereafter. Responsible Party: Administrator

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