Failure to Annually Review and Update Emergency Preparedness Program
Penalty
Summary
The facility failed to review and update its Emergency Preparedness Program (EPP) as required by federal regulations. During a record review with the Administrator and the Maintenance Director, surveyors found that there was no documented evidence showing the EPP had been reviewed and updated annually. This deficiency was identified during the survey process when the facility was unable to provide records demonstrating compliance with the annual review and update requirement for the EPP. Both the Administrator and the Maintenance Director acknowledged the absence of documentation regarding the annual review and update of the EPP during the exit conference. The Maintenance Director also concurred with the findings during the interview. No information was provided in the report regarding specific residents or their conditions at the time of the deficiency.