Emergency Preparedness Plan Lacks Key Provisions
Summary
The facility failed to comply with Disaster and Emergency Preparedness requirements as outlined by New York State regulation. Specifically, the facility's emergency preparedness plan did not include provisions for earthquake, flood, or nuclear disaster. This deficiency was identified during a recertification survey, where it was noted that there was no documented evidence of such provisions in the plan. During an interview, the facility's administrator acknowledged the absence of these provisions and indicated an intention to add them.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. Disaster Plans developed for Earthquake, Flood and Nuclear events and made part of the Comprehensive Emergency Management Plan. 2. All-Hazard Risk Assessment will be updated to include these required disaster plans; and will be reviewed to identify any other risk which may pose more than a theoretical or nominal risk to ensure plans are developed. 3. Employees will be notified via general information update (email) of the Comprehensive Emergency Management Plan additions, with a copy provided for review. Further education on these plans will be incorporated into annual facility training exercises and disaster drills based on their relative priority as determined by the facility’s risk assessment (previously assessed at ‘low risk’). Families or representatives will be provided an annual overview of the Comprehensive Emergency Management Plan. This information is not detail - plan specific, but a general overview of the facility's emergency response assessment, planning, etc. 4. The development of the respective policies are complete, and have become part of the Comprehensive Emergency Management Plan. Ongoing compliance with this deficiency - which is specifically the absence of these plans - will be reviewed annually as part of annual All Risk Assessment and Comprehensive Emergency Management Plan review. Responsible Party: Administrator
Penalty
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