Emergency Preparedness Deficiency: Missing Contact Information
Summary
The facility failed to comply with emergency preparedness requirements during a recertification survey. Specifically, the facility's Emergency Management Plan and Communications Plan lacked documented contact information for resident physicians and other health care facilities with which they have agreements. This deficiency was identified through record review and an interview with the Facilities Manager, who acknowledged the omission of the necessary contact information.
Plan Of Correction
Plan of Correction: Approved April 25, 2025 Element 1 The Emergency plan, communications was updated to include the contact information for the attending physicians, medical director, facilities included in our emergency preparedness plan. Element 2 The Emergency Plan, communications were reviewed to ensure all required elements included in the plan. No changes required. Element 3 Nursing educator will provide education to Leadership Team (i.e., Director of Nursing, social work, Rehabilitation manager, facilities manager, Assistant Director of Nursing, Dietary manager, Nurse managers) on the addition of the contact information in the plan. Education will include but not be limited to the following: The information in the communications plan and how to use information in the communications plan. Element 4 The Safety Committee will review the Emergency Preparedness plan monthly to ensure that the plan is up to date and includes all required elements per regulation. Review will be reported monthly at the facility quality assurance committee for review and recommendations. This review will continue as a standard agenda item for the monthly quality assurance meeting. Facility manager responsible for ongoing compliance.
Penalty
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