Failure to Conduct Emergency Preparedness Drills
Penalty
Summary
The facility failed to conduct any emergency preparedness drills within the last 12 months. During a document review on March 4, 2025, between 10:00 am and 12:00 pm, it was found that the facility's emergency preparedness policy and procedures lacked documentation of any emergency drills conducted in the specified period. The Director of Maintenance confirmed that no drills were conducted during this time.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 I. Immediate Corrections: a. Director of Environmental Services reviewed Emergency Preparedness Plan and found there to be inadequate safety measures, specifically documentation and execution of necessary emergency drills within the last 12 months. b. Administrator registered facility for NYC Health Long Term Care Exercise Program to ensure compliance moving forward. c. Administrator registered facility for tabletop exercise on (MONTH) 22 and (MONTH) 23rd via NYC LTC Associates / NYC DOHMH II. Identification: a. The facility respectfully acknowledges this deficiency affects all residents. III. Systemic Changes: a. Administrator and Director of Environmental Services reviewed Emergency Preparedness Plan. b. Administrator in-serviced all maintenance staff on Emergency Preparedness requirements including the mandatory drills done in last 12 months. IV. Monitoring: a. Director of Environmental Services developed a Disaster Drill audit to maintain compliance over required 12 month period. b. Audits will be done quarterly for 1 year. c. All negative findings will be immediately addressed. d. All audit findings will be presented to the QA committee quarterly by the Director of Environmental Services / designee. V. Responsibility: a. The Director of Environmental Services will be responsible to ensure correction of this deficiency.