Failure to Maintain Updated All-Hazards Risk Assessment
Penalty
Summary
Kadima Rehabilitation & Nursing at Lititz was found to be non-compliant with federal emergency preparedness requirements during a Medicare/Medicaid Recertification Survey. Specifically, the facility failed to provide an updated all-hazards risk assessment as required by regulation. This assessment is a critical component of the emergency preparedness plan and must be reviewed and updated at least annually for LTC facilities. The deficiency was identified through document review, which revealed the absence of an updated risk assessment for the facility. During the exit conference, both the Director of Nursing and the Director of Maintenance confirmed that they could not provide documentation of an updated all-hazards risk assessment. The lack of this documentation affected the entire facility component, as the risk assessment is necessary to identify and plan for potential emergency events, including missing residents and other hazards relevant to the facility's operation.
Plan Of Correction
1. We cannot retroactively correct. 2. The Hazard Risk Assessment will be updated. 3. Administration will be educated on the need for updating the Hazard Risk Assessment. 4. The EPP committee will review the updated risk assessment.