Facility Lacks Contingency Plan in Assessment
Penalty
Summary
The facility failed to ensure a contingency plan was developed and included in the Facility Assessment, which is necessary for identifying the resources needed to provide care and services during both regular operations and emergencies. During an interview and record review, the Administrator acknowledged that the Facility's Assessment was incomplete and did not include a contingency plan addressing staffing needs during emergencies that could affect resident care. The Administrator noted that the Facility Assessment should provide an overview of the resident population and reflect the services provided by the facility, including identifying risks and ensuring the facility can operate fully without delay during unforeseeable events. The facility's undated policy and procedure titled 'Facility Assessment' indicated that the assessment should inform contingency planning for events that do not require activation of the facility's emergency plan but could still impact resident care, such as the availability of direct care nurse staffing. Additionally, a review of CMS guidance clarified that facilities must conduct and document a facility-wide assessment to determine necessary resources for competent resident care during both day-to-day operations and emergencies. The lack of a contingency plan in the Facility Assessment had the potential to hinder the facility's ability to respond effectively during unexpected circumstances, potentially impacting resident care.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/12/25, the Administrator held a meeting that included the Medical Director, the Director of Nursing, Social Services Director, Activities Director, a Registered Nurse Supervisor, a License Vocational Nurse, two Certified Nursing Assistants to revise the facility's facility assessment to include a contingency plan. The contingency plan included having a pool of on-call staff to assist in providing additional staff needed in a case of events that does not require the facility to activate its emergency plan. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/14/25, the Administrator reviewed the facility's reported incidents to identify any events that required the facility to activate its facility assessment related to the contingency plan. There were no facility reported incidents that required an activation of the facility assessment's contingency plan. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Director of Nursing and Director of Staff Development in-serviced the Administrator on the facility's policy and procedure titled, "Facility Assessment," with emphasis on the facility using the Facility Assessment to inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to the availability of direct care nurse staffing or other resources needed for resident care. The in-service also included the "Revised Guidance for Long-Term Care Facility Assessment Requirements" with emphasis on conducting and documenting a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations including nights and weekends and emergencies. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for the facility assessment having a contingency plan for three months or until compliance is met.