Failure to Conduct Required Emergency Preparedness Drill
Penalty
Summary
The facility failed to develop and maintain an Emergency Preparedness Training and Testing plan as required by federal regulations. Specifically, the facility did not participate in a full-scale community-based emergency preparedness exercise within the last 12 months. This was confirmed during a record review and interview with the Maintenance Director and Administrator, where no documentation could be provided to show compliance with this requirement. During the review, it was found that the Emergency Preparedness Training program lacked evidence of participation in the mandated exercise. The Administrator confirmed that the facility had not taken part in a full-scale community-based drill, as required by 42 CFR §483.73(d)(2) for long-term care facilities. This deficiency was identified during a survey and affected all 120 residents in the facility at the time. The absence of participation in the required emergency preparedness exercise means that the facility did not meet the federal standard for testing its emergency plan. The surveyors noted that this failure could result in the facility not having adequate planning and preparation in place to protect the health and safety of residents and staff, as directly stated in the report.
Plan Of Correction
E 039 E039 - Emergency Preparedness Testing Requirements 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/09/25, the facility implemented an emergency preparedness training program for staff. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/09/25, the facility implemented an annual Emergency Preparedness training and testing calendar and established a system for tracking staff participation. On 05/09/25, the Maintenance Director educated by the Administrator on the requirements and documentation for Emergency Preparedness Training. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will review the emergency preparedness training program schedule monthly to ensure required drills are completed. 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. --- K345 - Fire Alarm System: Testing and Maintenance 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/08/2025, the facility's licensed fire safety vendor completed the missing annual battery charger test and the 30-minute battery discharge test for the fire alarm control panel. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/08/2025, the Maintenance Director educated by the Administrator on the requirements and documentation for Fire Alarm System: Testing and Maintenance. 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 Fire Alarm testing log to ensure required testing; including battery charger and discharge tests are scheduled and completed. 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.