Failure to Annually Review and Update Emergency Operations Plan
Penalty
Summary
The facility failed to maintain compliance with federal regulations requiring the annual review and update of its Emergency Operations Plan (EOP). During a record review and interview with the Director of Subacute and the Director of Plant Operations, it was found that the EOP had last been reviewed and updated on 11/29/22. This was confirmed when the Director of Plant Operations stated that they believed the plan only needed to be reviewed every two years, following the hospital's review schedule, rather than annually as required for long-term care facilities. This deficiency affected all 59 patients in the facility, as the EOP had not been reviewed or updated within the required annual timeframe. The lack of timely review and update of the emergency preparedness plan could result in the facility being unprepared in the event of an emergency or disaster, as the plan may not reflect current procedures, resources, or risks.
Plan Of Correction
E 004 The director of plant operations revised the emergency operations plan. The emergency management committee approved the revised emergency operations plan and will be presented to the Subacute Quality Assurance and Performance Improvement committee for final approval. The Director of plant operations will be revising the emergency operations plan on an annual basis (within the first quarter of the year).