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E0004
C

Lack of Annual Review Documentation for Emergency Preparedness Plan

Lititz, Pennsylvania Survey Completed on 07-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide documentation verifying that its emergency preparedness plan was reviewed within the previous twelve months. During a document review on July 1, 2025, surveyors were unable to locate evidence that the emergency preparedness plan had been reviewed by the Emergency Preparedness Plan (EPP) committee as required. An interview conducted at the exit conference with the Director of Nursing and the Director of Maintenance confirmed the absence of documentation showing that the emergency preparedness plan had been reviewed in the past year. No additional information regarding specific residents or patient conditions was provided in the report.

Plan Of Correction

1. We can not retroactively correct. 2. The Emergency Preparedness plan will be reviewed by the EPP committee. 3. The Environmental Services Director will be educated on the need for EPP review. 4. The EPP plan review will be audited yearly in July.

See complete original report
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