Failure to Review Emergency Preparedness Plan Annually
Penalty
Summary
The facility was found to be deficient in maintaining its emergency preparedness plan as required by federal regulations. Specifically, the facility failed to provide documentation verifying that the emergency preparedness plan had been reviewed within the previous twelve months. This deficiency was identified during a document review conducted on April 8, 2025, at 9:55 AM. An interview with the Maintenance Director on the same day confirmed the absence of documentation to verify the review of the emergency preparedness plan. This lack of documentation affects the entire component of the facility's emergency preparedness program, indicating non-compliance with the requirement to review and update the plan annually.
Plan Of Correction
1. The emergency preparedness plan was reviewed and signed off on and placed in the emergency preparedness binder on 04-09-2025. 2. NHA, or designee, will ensure that facility emergency preparedness plan is reviewed at QAPI when all other manuals, policy and procedures are reviewed and signed off by appropriate department directors on an annual basis in June during QAPI each year.