Failure to Develop Emergency Plan Policies for Medical Documentation
Penalty
Summary
The facility failed to develop and implement emergency preparedness policies and procedures that included a system of medical documentation. This system is required to preserve patient information, protect the confidentiality of patient information, and secure and maintain the availability of records. The deficiency was identified during a document review conducted on May 1, 2025, at 8:15 a.m., which revealed the absence of such policies and procedures in the facility's Emergency Plan. An exit interview with the Maintenance Director on the same day at 10:30 a.m. confirmed the lack of documentation. This deficiency affects the entire facility, as it does not have the necessary policies and procedures in place to ensure the protection and availability of patient information during emergencies.
Plan Of Correction
Facility developed Emergency Plan policies and procedures that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records, affecting the entire facility. The Director of Maintenance or designee will audit to ensure Emergency Preparedness Plan policies and procedures are reviewed and preserves patients information and confidentiality at least annually, weekly x2, then monthly x2. All findings will be brought to QAPI for review.