Emergency Preparedness Plan Lacks Key Elements
Penalty
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. The deficiency was identified due to the absence of documented evidence in the emergency preparedness plan regarding the identification of the resident population served and their unique needs. Additionally, the plan lacked strategies to address these needs, a description of the types of services the facility could provide during an emergency, and how the facility would maintain continuity of care to protect residents' health and safety if normal operations were disrupted. This deficiency could potentially affect all residents at the facility.
Plan Of Correction
Plan of Correction: Approved January 23, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The Emergency Preparedness Plan was updated to reflect the types of services the facility could provide to their unique population of residents in the event of an emergency on 12/17/2024 and how the facility will maintain continuity of care to adequately protect the health and safety of our residents in the event of any limitations or cessation of normal operations during an emergency. The number of days of emergency supply of food, water, medical supplies, pharmaceutical supplies, generator fuel, disposable paper supplies, linen needs, etc. will be detailed in the updated plan. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The Emergency Plan will undergo a comprehensive review and update all sections that are deemed not current. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) The facility will complete a comprehensive review of the emergency plan annually and update where necessary to ensure it includes identification of the resident population and their needs, strategies used to address the needs of their residents, and a description of the types of services the facility can provide during an emergency. The administrator was educated by the regional administrator on completing a comprehensive annual review of the emergency plan. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The annual review of the emergency plan and all other emergency plan updates will be reviewed by the Quality Assurance Performance Improvement Committee annually and as needed when updates occur. Responsible Party: Administrator