Emergency Preparedness Deficiency Due to Outdated Succession Plan
Summary
Riverview Nursing and Rehabilitation Center was found to be non-compliant with the emergency preparedness requirements outlined in 42 CFR 483.73. During an emergency preparedness survey conducted on April 8, 2025, it was observed that the facility failed to maintain an updated Delegation of Authority succession plan. The plan, last updated in August 2020, contained names that did not match the current staff roster. This deficiency affected all three floors of the facility. The issue was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
Plan Of Correction
1. Facility has updated the Delegation of Authority succession Plan. 2. The facility Delegation of Authority will be reviewed and updated as needed. 3. NHA will educate the Receptionist to ensure the Delegation of Authority is completed as needed. 4. Facility Delegation of Authority will be audited weekly x4 then monthly x3 by NHA/Designee to ensure the plan is up to date. Audits will be reviewed at QAPI for further recommendations.
Penalty
Surveyors found that the facility's Emergency Preparedness Program listed satellite phones as an alternate means of communication, but the facility was unable to produce a satellite phone for inspection when requested. The Administrator confirmed that the alternate communication device was not available as required.
Failure to Provide Alternate Communication Device Listed in Emergency Plan
Penalty
Summary
During a Fire & Life Safety re-licensure survey, surveyors reviewed the facility's Emergency Preparedness Program (EP) and found that the facility had listed satellite phones as an alternate means of communication in their emergency plan. However, when requested, the facility was unable to produce a satellite phone for inspection. This deficiency was identified through both record review and staff interview, where the absence of the listed communication device was confirmed. The Administrator acknowledged the findings during the interview and at the exit conference, confirming that the alternate communication method described in the EP was not available as required by federal regulations. The deficiency specifically relates to the facility's failure to ensure that the alternate means of communication, as outlined in their emergency preparedness plan, was present and accessible for inspection.
Plan Of Correction
Corrective Action for Affected Residents: The administrator added an updated list of primary and alternate means of communication. The facility does not use satellite phones. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: The administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure primary and alternate means of communication for the facility are listed. Monitoring/Quality Assurance: The Emergency Preparedness Manual will be reviewed annually, and findings will be submitted to QAPI.
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