Failure to Conduct Required Emergency Preparedness Drill
Summary
The facility failed to ensure compliance with the emergency preparedness requirements as outlined in 483.73(d). During a documentation review and staff interview conducted on March 13, 2025, it was found that the facility did not conduct a required facility-based or community-based emergency preparedness drill. Although tabletop drills were conducted on April 23, 2024, and August 28, 2024, the necessary facility-based or community-based drill was missing. This deficiency was confirmed in an interview with the Director of Maintenance, who acknowledged that the required drill had not been conducted.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: A facility based or community based drill will be scheduled and completed by 4/18/2025. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: All residents have the potential to be affected, however no residents were negatively impacted. Element #3: The following system changes will be implemented to prevent reoccurrence: Maintenance staff and department heads will be in-serviced by the administrator on the requirements for LTC facilities to conduct exercises at least twice per year including unannounced staff drills and participation in an annual full-scale exercise that is either community based, or a facility based functional exercise. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: The Administrator has created an audit tool to track dates of disaster drills, type of disaster drill completed to ensure continued compliance. The Director of Maintenance/designee will audit 1 x week for 4 weeks then monthly thereafter for 3 months. Negative findings will immediately be reported to the administrator. Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25.
Penalty
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