Failure to Conduct and Document Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required exercises to test its emergency plan at least annually, as mandated by federal regulations. Specifically, record review on 05/07/2025 revealed that the facility did not perform a second full-scale exercise, tabletop exercise, or individual facility-based exercise that would qualify as a test of the emergency plan within the past year. No documentation was provided to demonstrate that any such exercise had taken place during the required timeframe. This deficiency was confirmed during an interview with the Facility Maintenance Director at the time of record review. The absence of documentation and lack of evidence for the required emergency preparedness exercises indicated non-compliance with the established emergency preparedness testing requirements. The report does not mention any specific patients, residents, or staff members directly affected at the time of the deficiency. The focus of the deficiency is on the facility's failure to meet regulatory requirements for emergency preparedness exercises and documentation, which could potentially impact all occupants in the event of an emergency.
Plan Of Correction
E039 1. The Administrator will conduct a review of the Emergency Preparedness plan and policies. The Maintenance Director will participate in/ conduct a community or facility-based exercise to test the Emergency Preparedness system. 2. The Administrator will review regulation E039 and provide education to the Maintenance team on the requirements. 3. The Maintenance Director and/or designee will utilize the preventative maintenance system to ensure exercises are scheduled annually. Results of the annual exercise will be brought to the Quality Assurance Performance Improvement meetings for review. The Committee will determine whether modifications to the plan are necessary. 4. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.