Deficient Emergency Preparedness Program
Penalty
Summary
The facility failed to establish and maintain a comprehensive Emergency Preparedness Program that was updated at least annually. During the Emergency Preparedness Plan review, it was found that the plan was last reviewed and updated on January 2, 2024, and November 10, 2021. No other documentation was available to indicate any further updates or reviews. This deficiency could potentially affect all residents in the facility.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 The Emergency Management Plan was reviewed and revised on 3/6/2025. Each section of the Emergency Management Plan reflects the review date and if revisions occurred. All Department Managers will receive education on developing, maintaining, and reviewing/updating the emergency preparedness program annually. The Director of Environmental Services and Administrator will review the Plan quarterly to ensure it is updated and revised. Any changes or revisions will be reviewed with the Quality Assurance and Performance Improvement Committee quarterly for 1 year to ensure compliance. Person Responsible for Completion: Administrator