Failure to Maintain and Update Emergency Preparedness Policies and Procedures
Penalty
Summary
The facility failed to maintain and update its Emergency Preparedness Plan (EPP) as required. During a document review and staff interview, it was found that there were no documents available to show that the Emergency Preparedness (EP) policies and procedures had been reviewed or updated at least annually. The date of the last review was unknown, and staff confirmed that the EPP policies and procedures had not yet been updated. This deficiency affected all 92 residents in the facility, as the lack of updated EP policies and procedures could result in a delay in protecting their health and safety during emergencies. The findings were based on direct document review and staff interviews conducted during the survey.
Plan Of Correction
The EVS Director or designee will conduct quarterly audits of the EPP to ensure it remains updated. The results of these audits will be reported during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. Any deficiencies identified during audits will be addressed immediately, and corrective actions will be documented. **Date of Compliance: 4/18/25** **E 013: Development of EP Policies and Procedures** 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 (EP) Policies and Procedures 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 Emergency Preparedness (EP) Policies and Procedures to ensure all protocols for the protection of all residents during emergencies. An audit will be conducted on 4/10/25 to verify that all Emergency Preparedness (EP) Policies and Procedures 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 Emergency Preparedness (EP) Policies and Procedures 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 Emergency Preparedness (EP) Policies and Procedures by the new year. The facility's emergency preparedness committee will convene quarterly to review emergency protocols and make any necessary revisions. The EVS Director was retrained on the importance of maintaining an updated Emergency Preparedness (EP) Policies and Procedures 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. The EVS Director or designee will conduct quarterly audits of the Emergency Preparedness (EP) Policies and Procedures to ensure it remains updated. The results of these audits will be reported during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. Any deficiencies identified during audits will be addressed immediately, and corrective actions will be documented.