Failure to Maintain Emergency Preparedness Plan with Required Risk Assessment
Penalty
Summary
The facility failed to provide a written Emergency Preparedness (EP) Plan that included a facility-based and community-based risk assessment, as required by regulations. During a document review and interview conducted on July 7, 2025, it was found that the EP plan did not contain an annually updated risk assessment utilizing an all-hazards approach. This assessment is necessary to identify and address potential emergency events, including missing residents, as part of the facility's preparedness planning. Interviews with the Facility Administrator and Maintenance Director confirmed the absence of the required documentation in the EP plan. The deficiency was identified through both the review of the facility's emergency preparedness documentation and direct confirmation from facility leadership.
Plan Of Correction
A written Emergency Preparedness Plan that includes a facility-based and community-based risk assessment is now present in the facility. The Maintenance Director/designee will complete a check of the written Emergency Preparedness Plan to ensure it includes an annually updated facility-based and community-based risk assessment, utilizing an all-hazards approach. To ensure compliance, this check will be performed monthly for three months. Findings will be reviewed at monthly Quality Assurance Meetings.