Failure to Conduct and Document Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required exercises to test its emergency preparedness plan as mandated by federal regulations. Specifically, there was no documentation provided for an annual full-scale facility-based exercise or a full-scale community-based exercise. Additionally, there was no evidence of an actual event that would qualify as a test of the emergency plan, nor was there documentation of a tabletop exercise within the last year. During the survey, a review of the facility's emergency preparedness records revealed the absence of records demonstrating compliance with the annual testing requirements. The surveyor noted that the facility did not provide any documentation of having conducted the necessary drills, exercises, or actual emergency events that would satisfy the regulatory requirements for emergency preparedness testing. These findings were confirmed through an interview with the Facility Administrator at the time of record review. The lack of documentation and failure to conduct the required exercises constituted a deficiency in the facility's emergency preparedness program. This deficiency was noted to potentially affect all 61 occupants in the event of a facility-wide or community disaster, as stated in the report.
Plan Of Correction
E0039 #1 Facility failed to conduct exercises to test the Emergency Preparedness Plan at least annually. #2 Facility Maintenance Director was educated on putting Emergency Preparedness Drill copies into the Life Safety Book when completed. #3 Maintenance Director retrieved and made copies of both the Table Top Drill and an actual Emergency Drill. #4 Any further Table Top drills and/or conducted Emergency Preparedness Drill exercises will be conducted at least annually, and paperwork will be kept in the Life Safety Manual. #5 It will be the responsibility of the Maintenance Director to continue to conduct Emergency Plan Exercises at least annually.