Emergency Preparedness Plan Lacks Comprehensive Policies
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included comprehensive policies and procedures addressing the patient population, particularly persons at-risk, the types of services the facility could provide during an emergency, and the continuity of operations. This deficiency was identified during a document review conducted on May 1, 2025, at 8:15 a.m., which revealed that the plan did not adequately cover these critical areas, affecting the entire facility. An exit interview with the Maintenance Director on the same day at 10:30 a.m. confirmed the absence of necessary documentation in the Emergency Preparedness Plan. The lack of documentation indicates that the facility did not have a structured approach to managing emergencies, particularly concerning at-risk individuals and operational continuity, which is a requirement under §483.73(a)(3).
Plan Of Correction
The facility will ensure policies and procedures were in place addressing patient population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans, affecting the entire facility. Facility updated Emergency Preparedness Plan to include policies and procedures that addressed persons at-risk, affecting the entire facility.