Failure to Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to comply with emergency preparedness guidelines as required by federal regulations. During a document review on April 8, 2025, it was discovered that the last annual review of the facility's emergency preparedness plan was conducted on January 17, 2019. This indicates that the facility did not perform the required annual review and update of the emergency preparedness plan for several years, which is a clear violation of the regulatory requirements. An interview with the maintenance director on the same day confirmed that the facility was unable to provide documentation of an updated annual review date at the time of the survey. This lack of documentation further substantiates the facility's failure to maintain compliance with the emergency preparedness guidelines, as they could not demonstrate that the plan had been reviewed and updated as mandated.
Plan Of Correction
1. Administrator and Maintenance Director conducting review and updates for emergency preparedness plan. 2. Emergency preparedness plan will be updated by 5/12/2025. 3. Administrator and Maintenance Director will provide all staff education on emergency preparedness plan. 4. All staff education will be completed by 5/14/2025.