Deficient Emergency Preparedness for Subsistence Needs
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure the provision of subsistence needs for staff and patients during an emergency, as required by federal regulations. Specifically, the emergency preparedness plan did not include documentation of an established relationship or emergency contract with a water supplier to provide drinking water in the event of an emergency. Although the plan referenced the intention to secure such an agreement, no evidence was provided to confirm that this had been accomplished by the time of the survey exit. Additionally, the facility's emergency plan cited the use of an onsite well as an alternative water source during emergencies. However, interviews with the Maintenance Director and his assistant revealed that neither had observed the well functioning during their respective tenures of approximately three and sixteen years. This lack of operational verification further demonstrated the facility's failure to ensure reliable access to water for subsistence needs in emergency situations.
Plan Of Correction
1. The facility failed to establish relations and obtain an agreement with a water supplier to provide the facility water in the event of an emergency. 2. Failure to ensure the facility has an agreement with a drinking water supplier could affect all residents, employees, and visitors in the event of an emergency. 3. The maintenance director has obtained an emergency drinking water agreement with Norway Springs to provide the facility with drinking water in the event of an emergency. The maintenance director has been educated on the importance of maintaining drinking water sources/agreements. 4. The Administrator is responsible for ensuring drinking water agreements are established and implemented at the facility and report to the QA committee. 5. The facility failed to maintain an accurate policy for emergency water within the emergency preparedness plan, specifically pertaining to the use of an existing onsite water well resource. 6. Failure to ensure all water emergency water sources are in place and accurate could affect all residents, employees, and visitors in the event of an emergency. 7. The onsite water well is currently not in use and has been removed from the facility emergency preparedness plan. The maintenance director has been educated on the importance of maintaining accurate emergency water resources and policies within the facility. 8. The Administrator is responsible for the implementation of accurate policies and procedures pertaining to emergency water in the event of an emergency and report to the QA committee.