Failure to Maintain Updated All-Hazards Risk Assessment
Penalty
Summary
Schuylkill Center was found to be noncompliant with federal emergency preparedness requirements following an Emergency Preparedness Survey. The facility failed to provide an updated all-hazards risk assessment, which is required to be reviewed and updated at least annually. During document review, surveyors were unable to obtain documentation of a current all-hazards risk assessment for the facility. At the time of the exit conference, both the Administrator and Maintenance Director confirmed that they could not provide an updated all-hazards risk assessment. This deficiency affected the entire facility component and was based solely on the lack of required documentation. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Plan Of Correction
The facility will continue to provide an updated all hazards risk assessment for the facility. 1. The facility utilizes the Kaiser Permanente Hazard Vulnerability Assessment Tool, which was last updated at the time of annual manual approvals on 1/17/2025. This tool will be updated at least quarterly, or as needed, and used to identify and update the facility's Emergency Preparedness plan. The Hazards Risk Assessment will be filed in all copies of the Emergency Preparedness plan. 2. The Maintenance Director or designee will audit the Hazard Vulnerability Assessment tool at least semi-annually to confirm that updates are filed in all copies of the Emergency Preparedness plan. Results of the audits will be reviewed at least semi-annually with the QAPI Committee, including any revisions required to the Facility Emergency Preparedness plan as a result of the assessment. Date of Correction is 7/30/2025.