Deficiency in Emergency Preparedness Plan
Penalty
Summary
The facility was found to be non-compliant with Disaster and Emergency Preparedness requirements during a recertification survey. Specifically, the facility's emergency preparedness plan lacked provisions for nuclear accidents, reception of mass casualty victims, and chemical spills, as mandated by New York State regulations. This deficiency was identified through interviews, where it was revealed that there was no documented evidence of these provisions being included in the emergency preparedness plan. During an interview, the administrator acknowledged the absence of these critical components in the plan.
Plan Of Correction
Plan of Correction: Approved April 25, 2025 No residents were affected by this deficient practice. All residents have the potential to be affected by this deficient practice. All staff will be educated on the provisions for nuclear accident, reception of mass casualty victims, and chemical spills. The Emergency Plan will be updated to include provisions for nuclear accident, reception of mass casualty victims, and chemical spill. On a quarterly basis, the facility Emergency Plan will be reviewed by the Quality Assurance Performance Improvement committee to ensure all appropriate policies and provisions are included. The Administrator or Designee is responsible for this plan of correction.