Emergency Preparedness Plan Lacks Critical Resident Information
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. The deficiency was identified through a record review, which revealed that the facility's emergency plan, dated 03/31/2024, lacked documentation regarding the resident populations at risk during an emergency and the specific services in place to address their unique vulnerabilities. The plan did not include identification of the resident population served, strategies to address their needs, a description of services the facility could provide during an emergency, or how continuity of care would be maintained to protect residents' health and safety if normal operations were disrupted. This deficiency could potentially affect all residents at the facility. During an interview, the Director of Emergency Management and Life Safety acknowledged the need to update the emergency preparedness plan to include this critical information.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 1. Champlain Valley Physicians Hospital will revise that the Emergency Operations Plan includes all Skilled Nursing Unit residents and addresses the unique needs of the population. A. Strategies the facility had put in place to address the needs of the population, B. Description of the types of services the facility could provide in the event of an emergency, and C. How the facility would maintain continuity of care to their client population to adequately protect their health and safety in the event of limitations or cessation of normal operations during an emergency. Review will be conducted by (MONTH) 15, 2025. 2. All skilled nursing facility residents have the potential to be affected by alleged deficient practice. 3. The Skilled Nursing Facility staff will be educated on the revised Emergency Operations Plan annually and as needed. 4. The Director of Emergency Management will conduct one policy audit per quarter, and as needed, to confirm: - Identification of the resident population served and their unique needs, - Strategies the facility had put in place to address the needs of the population, - Description of the types of services the facility could provide in the event of an emergency, and - How the facility would maintain continuity of care to their client population to adequately protect their health and safety in the event of limitations or cessation of normal operations during an emergency. All revisions to the Emergency Operations Plan will be reviewed at Skilled Nursing Facility Quality Assurance Committee for recommendations and approval. 5. Director of Life Safety & Emergency Management.
Penalty
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