Failure to Document Emergency Preparedness Exercises
Penalty
Summary
Spring Hill Rehabilitation and Nursing Center was found to be non-compliant with the emergency preparedness requirements as outlined in 42 CFR 483.73. The facility failed to maintain the necessary documentation for the two required annual exercises to test their emergency plan. This deficiency was identified during an Emergency Preparedness Survey conducted on April 8, 2025. During the survey, an interview and documentation review revealed that the facility lacked the required documentation for the two exercises meant to test the emergency plan. This was confirmed during an interview with the Interim Facility Administrator and the Plant Operations Manager, who acknowledged that the documentation was not available at the time of the survey. The absence of documentation for these exercises indicates a failure to comply with the regulatory requirements for emergency preparedness. The facility's inability to provide evidence of conducting these exercises suggests a lapse in maintaining and testing their emergency plan, which is crucial for ensuring the safety and preparedness of the facility in the event of an emergency.
Plan Of Correction
1. There were no negative outcomes due to the lack of disaster drills. 2. The facility will schedule and conduct a full-scale facility based disaster drill and will conduct drills semi-annually thereafter. 3. The minutes of the drill will be submitted to the facility QAPI committee for review and approval.