Failure to Maintain and Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to maintain and update its Emergency Preparedness Plan (EPP) as required by federal regulations. During a document review and staff interview, surveyors found that there was no documentation to show that the EPP had been reviewed or updated at least annually. The date of the last review was unknown, and staff confirmed that the EPP had not yet been updated. This deficiency affected all 92 residents in the facility, as the lack of an updated EPP could impact the facility's ability to protect their health and safety during emergencies. The findings were based on direct document review and staff interviews conducted by surveyors.
Plan Of Correction
E 004 Develop EP Plan, Review, and Update Annually How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The facility initiated a review and update of the Emergency Preparedness Plan (EPP) upon identification of the deficiency. The facility's leadership and emergency preparedness team have reviewed the updated plan on 4/9/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected. The facility will update the EPP to ensure all protocols for the protection of all residents during emergencies. A facility-wide audit will be conducted on 4/10/25 to verify that all emergency preparedness procedures and documentation are up to date. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: The facility has established a process to review and update the EPP annually. The policy now requires the administrator or designee to document the annual review in a designated log. A calendar reminder has been set for December 1st of each year to ensure timely review and update of the EPP by the new year. The facility's emergency preparedness committee will convene quarterly to review emergency protocols and make any necessary revisions. Maintenance director was retrained on the importance of maintaining an updated EPP, by the Administrator on 4/9/25. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system.