Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to ensure that its communication plan included a method for providing necessary information to the incident command center or the authority having jurisdiction during an emergency. During a life safety recertification survey, it was discovered that the facility's emergency preparedness binder lacked a policy and procedure for sharing information about its occupancy, needs, and ability to provide assistance. This deficiency was identified through documentation review and confirmed during an interview with the Administrator, who acknowledged the absence of this critical information in the emergency preparedness binder.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 Corrective Actions for Residents Identified: ò All residents, visitors and staff have the potential to be affected by the deficient practice. ò Policy for sharing information regarding occupancy, needs and the ability to provide assistance was located. Resident at Risk: ò All residents, visitors and staff have the potential to be affected by the deficient practice. Systemic Changes: ò Policy reviewed and no revision needed. ò Education to the Director of Plant Operation on the importance of having policy readily available. ò Policy added to the emergency preparedness binder. Monitoring of Corrective Actions: ò The Director of Plant Operations or Designee will conduct a monthly audit to ensure that the policy for sharing information regarding occupancy is in the Emergency Preparedness plan for each location weekly x4 monthly x3, or until 100% compliance. ò If non-compliance is found this will be reported to the administrator and the Director of Plant Operations. ò All findings will be submitted to monthly QAPI. ò QAPI Committee will determine if further action is needed. Responsible: The Director of Plant Operations or designee.