Deficiency in Emergency Preparedness: Lack of Sewage and Waste Disposal Procedure
Penalty
Summary
The facility failed to incorporate procedures for sewage and waste disposal into their Emergency Preparedness Program (EPP) for all 56 residents. This deficiency was identified during a record review conducted with the Maintenance Director and the Regional Maintenance Consultant. The review took place on March 31, 2025, between 9:30 a.m. and 1:30 p.m. During this review, it was found that the facility did not have a procedure in place for sewage and waste disposal in the event of a system loss. An interview with the Maintenance Director and the Regional Maintenance Consultant confirmed the absence of this procedure. These findings were subsequently discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during an exit conference held on the same day between 4:15 p.m. and 4:30 p.m. The lack of a sewage and waste disposal procedure is a violation of the Code of Federal Regulations, specifically 42 CFR § 483.73(b)(1)(D).
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The QA & A committee will review to approve the procedure for sewage and waste disposal on 4/24/2025. 2. No other areas or residents were affected by deficient practice. 3. Education provided to the Maintenance Director by NHA or designee on procedures for sewage and waste disposal by 4/24/2025. 4. All policies and procedures will be reviewed and monitored annually by the QA & A committee.