Failure to Annually Review Emergency Preparedness Plan
Summary
The facility failed to ensure that its emergency preparedness (EP) plan was reviewed and updated at least annually, as required by Emergency Preparedness 483. During a Life Safety recertification survey, it was observed that the emergency preparedness binders on both the first and second floors had not been reviewed since the year (YEAR). This deficiency was confirmed through documentation review and staff interviews. A nursing staff member indicated that the EP binder is used as a reference, while the Director of Nursing stated that staff could access the information from the computer.
Plan Of Correction
Plan of Correction: Approved March 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Director of Facilities discarded outdated hard copies of Emergency Preparedness Plan noted on 2 out of 2 resident floors and replaced them with updated hard copies of the Emergency Preparedness Plan last revised in (MONTH) of 2024. - Director of Nursing will complete in-service education with Licensed Staff on accessibility of Emergency Preparedness Plan by 4/15/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Beginning on 3/31/25 Director of Facilities will conduct monthly reviews of the Emergency Preparedness Binders on Pavilion 1 and 2 as well as electronic versions to ensure continued regulatory compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities
Penalty
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