Failure to Maintain and Update Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain and update its Emergency Preparedness Plan (EPP), specifically the Communication Plan component, as required by federal regulations. During a document review and staff interview, it was found that there were no records indicating the Communication Plan had been reviewed or updated at least annually. The last review date of the Communication Plan was unknown, and staff confirmed that the update had not yet occurred. This deficiency could affect all 92 residents in the facility, as the lack of an updated Communication Plan may delay the protection of their health and safety during an emergency. The findings were based on direct document review and staff interviews, with no evidence provided to show compliance with the annual review and update requirement for the Communication Plan.
Plan Of Correction
E 029: Development of Communication Plan 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 Communication Plan 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 Communication Plan to ensure all protocols for the protection of all residents during emergencies. An audit will be conducted on 4/10/25 to verify that the Communication Plan is 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 Communication Plan 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 Communication Plan by the new year. • The facility's emergency preparedness committee will convene quarterly to review the Communication Plan and make any necessary revisions. • The EVS Director was retrained on the importance of maintaining an updated Communication Plan, by the Administrator on 4/9/25.