Deficiency in Emergency Preparedness Communication
Penalty
Summary
The facility was found deficient in ensuring a method for sharing information from the emergency preparedness plan with residents and their families or representatives, as required by Section 483.73. During the Life Safety recertification survey, it was observed that the facility's Emergency Preparedness plan lacked a policy and procedure for communicating components of the emergency plan to residents, their families, or representatives in the event of an emergency. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of such a policy and procedure in the plan.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 All residents, visitors, and staff have the potential to be affected by the deficient practice. Policy for sharing components of the emergency preparedness plan with residents, families, and representatives was located. Resident at Risk: All residents, visitors, and staff have the potential to be affected by the deficient practice. Systemic Changes: - Policy reviewed and no revision needed. - Education to the Director of Plant Operations on the importance of having policy readily available. - Policy added to emergency preparedness binder. Monitoring of Corrective Actions: - The Director of Plant Operations or Designee will conduct a monthly audit to ensure that the policy for sharing information is in the Emergency Preparedness plan for each location weekly x4 monthly x3, or until 100% compliance. - If non-compliance is found, this will be reported to the administrator and the Director of Plant Operations. - All findings will be submitted to monthly QAPI. - QAPI Committee will determine if further action is needed. Responsible: Director of Plant Operations or Designee.