Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required annual full-scale exercise or an accepted substitution, as well as an additional exercise or accepted substitution, within the previous 12 months. This deficiency was identified during a document review conducted on May 1, 2025, at 8:15 a.m. The review revealed that the facility did not meet the emergency preparedness testing requirements outlined in §483.73(d)(2), which mandates that long-term care facilities conduct exercises to test their emergency plans at least twice per year. The deficiency affects the entire facility, as the lack of proper emergency preparedness exercises could impact the facility's ability to effectively respond to emergencies. The regulations require participation in a community-based full-scale exercise annually, or if not accessible, a facility-based functional exercise. Additionally, an extra exercise, such as a mock disaster drill or tabletop exercise, must be conducted annually. The facility's failure to conduct these exercises indicates non-compliance with federal regulations. During the exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., it was confirmed that there was a lack of documentation to support the completion of the required exercises. This lack of documentation further substantiates the facility's failure to adhere to the emergency preparedness requirements, as there is no evidence to demonstrate that the necessary exercises were conducted or that the emergency plan was adequately tested and revised as needed.
Plan Of Correction
The facility will conduct the Emergency Plan's required annual full-scale exercise, a mock disaster drill, and a tabletop exercise affecting the entire facility. These will be done within the next 2 months. NHA will audit monthly x2; results will be brought to QAPI for review.