Failure to Maintain Emergency Preparedness Testing Requirements
Penalty
Summary
The facility failed to maintain compliance with emergency preparedness testing requirements as outlined in federal regulations. During a record review and interviews with the Director of Subacute and the Director of Plant Operations, surveyors requested documentation of the facility's Emergency Operations Plan and evidence of participation in required emergency preparedness exercises. The facility was unable to provide documentation showing participation in an annual full-scale community-based exercise or an additional annual full-scale exercise to test the emergency plan. The Director of Plant Operations indicated that they needed to locate the after-action report for an actual emergency event that had occurred in the past year, but this documentation was not provided by the deadline given by surveyors. The lack of documentation meant that the facility could not demonstrate compliance with the requirement to conduct at least two emergency preparedness exercises per year, including unannounced staff drills using emergency procedures. This deficiency affected all 59 residents in the facility at the time of the survey. The survey findings were based on the absence of required records and the inability of facility leadership to produce evidence of compliance with emergency preparedness testing standards during the annual Life Safety Code recertification survey.
Plan Of Correction
E 039 Facility was compliant with frequency of drills/actual events as evidenced by the following documents: On 5/30/2024, incident command was set up internally for a water pipe ruptured in the ceiling of a non-patient care hallway. This is contiguous to a supply room and near the kitchen. Code Triage Internal was called and facility engineers were already on-site mitigating the issue. Water was shut off to the building at the street. County and state were notified. (Please see the attachment) On 2/19/2025, incident command was set up due to phone outage and inability to receive incoming calls or make outgoing calls. Internal unit to unit and employee mobile phones being utilized to support communication. First information from IT is that is not a switch issue, but more widespread and involves AT&T. In addition, Pyxis is on critical override. Intermittent computer down. (Please see the attachment). PLAN: Facility will continue to perform mock disaster drills as scheduled per our Environment of Care (EOC)/Emergency Management (EM)/Life Safety (LS) in accordance with state and county guidelines and participate in tabletop exercises with the county and other agencies. All documents will be maintained by the disaster coordinator. A scheduled tabletop exercise is planned for October 16th, 2025 in collaboration with local and State agencies, "The great California shakeout".