Deficiency in Emergency Preparedness Program
Penalty
Summary
The facility failed to incorporate the use of volunteers and other emergency staffing strategies in their Emergency Preparedness Program (EP) as required by the Code of Federal Regulations (CFR). During a record review conducted on April 30, 2025, it was found that the facility's EP lacked policies and procedures detailing the process and role for integrating State and Federally designated health care professionals to address surge needs during an emergency. This deficiency was identified during a review of the facility's documentation with the Administrator. An interview with the Administrator, conducted concurrently with the record review, confirmed the absence of these critical policies and procedures. The Administrator acknowledged the findings, which were subsequently reviewed with both the Administrator and the Director of Plant Operations during the exit conference on the same day. The lack of a comprehensive plan for utilizing volunteers and integrating designated health care professionals during emergencies represents a significant gap in the facility's emergency preparedness efforts.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The Executive Director was educated by the Regional Director of Operations on 05/16/2025 regarding E024. The policy for E024 was updated by the Executive Director on 05/16/2025 to reflect the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. The policy was approved by the QAPI committee on 05/21/2025. The policy will be maintained in the Executive Director's office and reviewed annually or as needed.