Failure to Conduct and Document Required Emergency Preparedness Exercise
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 exercise within the last 12 months. During the annual Life Safety Code recertification survey, the surveyors requested documentation of such participation, but the facility was unable to provide any records indicating compliance with this requirement. The only documentation provided by the facility was a certificate for participation in the 2024 Great California ShakeOut. However, the facility did not supply an after action report or any record of staff participation related to this exercise. This lack of documentation meant that the surveyors could not verify whether the exercise met the regulatory requirements for a full-scale community-based emergency preparedness drill. During an interview, the Administrator acknowledged that the exercise was overlooked. As a result, the facility was found to be out of compliance with the emergency preparedness testing requirements, which affected all 35 residents in the facility at the time of the survey. No specific details about individual residents' medical histories or conditions were provided in relation to this deficiency.
Plan Of Correction
E 039 E 039 E 039 --- 1. Corrective Action: An after action participation report that will show actual involvement and activity in the community based exercise of the staff will be created on future community based exercise. II. How the facility will identify other residents: All residents have the potential to be affected by this practice. III. Systemic Change: Emergency Preparedness Communication plans will be reviewed and updated annually. IV. Monitoring Process: The facility will monitor its performance through our QAPI process. V. Date of correction: 06/13/2025