Missing Emergency Preparedness Policy for 1135 Waiver Alternate Care Site
Penalty
Summary
The facility failed to develop and implement policies and procedures outlining its role in providing care and treatment at an alternate care site under an 1135 waiver, as required by federal regulations. During a document review and interview with the Maintenance Director and Administrator, surveyors requested the Emergency Preparedness policies and procedures. The facility was unable to provide documentation indicating a plan for the provision of care at an alternate location in the event of an emergency requiring activation of an 1135 waiver. The Administrator, who was new to the facility, stated she was not aware that the required policy was missing. The absence of this policy affected all 120 residents in the facility. The facility was given an opportunity to submit the missing records by a specified deadline, but no records were received by the survey agency.
Plan Of Correction
E 026 E026 - Roles Under a Waiver Declared by the Secretary 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/12/2025, the Emergency Preparedness Plan was updated to include a policy addressing alternate care sites and adjusted staffing/licensure protocols. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected in the event of a federally declared emergency requiring relocation or altered care settings. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: The facility incorporated all guidelines into the Emergency Plan and added procedures for continuity of care in alternate locations on (date). 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 inspection of the Emergency Plan to ensure waiver protocols are included and current. 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.