Failure to Annually Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan was reviewed and updated at least annually, as required by federal regulations for long-term care facilities. During a document review conducted on May 1, 2025, it was discovered that the plan had not been reviewed and updated within the required timeframe. This oversight affects the entire facility, as the emergency preparedness plan is a critical component of ensuring the safety and well-being of all residents and staff in the event of an emergency. An exit interview with the Maintenance Director on the same day confirmed the lack of documentation regarding the review and update of the Emergency Preparedness Plan. This indicates a lapse in the facility's compliance with federal emergency preparedness requirements, which mandate that such plans be maintained and updated annually to address potential hazards and ensure readiness for emergencies.
Plan Of Correction
Facility established and maintaining a comprehensive emergency preparedness program that meets the requirements. The Director of Maintenance or designee will audit to ensure Emergency Preparedness Plan policies and procedures are reviewed and updated at least annually, weekly x2, then monthly x2. All findings will be brought to QAPI for review.