Failure to Update Emergency Preparedness Plan Annually
Summary
The facility failed to ensure that its Emergency Preparedness Plan was reviewed and updated at least annually, as required by 42 CFR 483.73(a). During a document review on the 22nd of the month, it was discovered that the last update to the Emergency Preparedness Plan was conducted on October 18, 2022. Additionally, the approval and implementation sheet listed former personnel as the Administrator and Director of Building Services, rather than the current individuals in these roles. On the 24th of the month, the Administrator confirmed that the plan had not been updated since they assumed their role in 2024, acknowledging the oversight and indicating an intention to review and update the plan.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 I. Immediate corrective action. On 01/24/2025, a review and update was conducted for the Emergency Management Plan. Upon inspection of the facility's Emergency Preparedness Binder, the Emergency Management Plan was found to be current with all regulatory requirements. The reviewed by sheet was signed and dated and put in the front of the binder for compliance. II. Identification of Others. To further ensure compliance and safety, all sections of the binder were reviewed in its entirety to ensure it had retained inspection sheets and their label/tab; this audit did not yield any insufficiencies or concerns for compliance and safety. III. Systemic Changes 1. The Administrator and Maintenance Director have been provided a comprehensive and detailed in-service regarding 'E-004', inclusive of but not limited to: the deficiencies observed during the environmental survey led by the NYS DOH, staff responsibility in continuous auditing, and the immediate reporting of findings to the Director of Maintenance or Administrator as applicable, so corrective action or repair may immediately ensue. All binders, and their respective sections, will be appropriately labeled as we proceed. The Emergency Manual will be inspected annually and signed on the reviewed by sheet and dated. 2. An audit tool has been created and implemented by the Director of Maintenance to identify any/all potential deficiencies of 'E-004'. This audit will occur monthly for the first three months of its implementation, then after, quarterly three times. IV. Quality assurance All audits of 'E-004' and any subsequent findings will be presented with the Administrator and interdisciplinary team at quality assurance and performance improvement (QAPI) meetings, held on a monthly basis. V. Individual Responsible for Correction. The Director of Maintenance is responsible for the completion of this correction.
Penalty
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