Emergency Preparedness Plan Lacks Key Strategies
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. Specifically, the facility's emergency preparedness plan lacked documented strategies for addressing certain emergency events identified in the facility's risk assessment. These missing strategies included plans for the loss of call bell, loss of emergency generator, and cyber-attack. This deficiency was identified through record review and an interview with the Director of Emergency Management and Life Safety, who acknowledged the absence of these plans in the emergency preparedness documentation.
Plan Of Correction
Plan of Correction: Approved March 12, 2025 1. The Emergency Preparedness Plan will be reviewed and revised. B. The Emergency Preparedness plan will be revised to include response actions that address loss of generator, loss of nurse call, cyber-attack, and missing residents specific to the Skilled Nursing Facility. Review of the Emergency Preparedness Plan will be complete by (MONTH) 15, 2025. 2. The skilled nursing facility will review and revise the Emergency Operations Plan to ensure compliance with all emergency preparedness requirements. 3. The Skilled Nursing Facility staff will be educated on the policies for loss of generator, loss of nurse call, cyber-attack, and missing residents on an annual basis and with any changes to the Emergency Preparedness plan. 4. The Director of Life Safety and Emergency Preparedness Plan will review the Emergency plan annually at a minimum and as needed to ensure all emergency events in the facility risk assessment are addressed. B. The Emergency Preparedness plan will be presented quarterly at the skilled nursing facility Quality Assurance and Performance Improvement committee and as needed for approval. 5. The Director of Life Safety & Emergency Management.
Penalty
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