Missing Emergency Staffing and Volunteer Policy in EP Plan
Penalty
Summary
The facility failed to maintain its Emergency Preparedness (EP) plan by not providing a policy and procedure that explains the use of volunteers or other emergency staffing strategies. During a document review and interview with the Maintenance Director and Administrator, surveyors requested the EP policies and procedures and found that there was no documentation addressing the facility's use of volunteers or integration of state and federally designated health care professionals to address surge needs during an emergency. The Administrator, who had recently started working at the facility, was unaware of the missing policy. This deficiency affected all 120 residents in the facility, as the lack of a documented policy could result in an ineffective emergency preparedness plan. The facility was given an opportunity to submit the missing records, but no records were received by the specified deadline.
Plan Of Correction
E024 - Policies/Procedures: Volunteers and Staffing 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/12/25, the facility developed a written policy outlining procedures for the use of volunteers and alternative staffing during emergencies. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected during emergency staffing shortages or volunteer involvement. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/2025, the policy was incorporated into the facility's Emergency Preparedness Plan. All department heads were trained on how to implement the policy during an emergency. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of the Emergency Preparedness Plan. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved. E 024