Missing Emergency Preparedness Procedures for 1135 Waiver
Penalty
Summary
The facility failed to include procedures in its Emergency Preparedness (EP) Plan that address the role of the facility under a waiver declared by the Secretary of the Department of Health, as required by Section 1135 of the Act. During a review of the EP Plan and interviews conducted, it was found that the plan did not contain written procedures for the provision of care at an alternative care site identified by emergency management officials during such a waiver. This deficiency was confirmed through both documentation review and interviews with the Facility Administrator and Maintenance Director, who acknowledged that the EP plan lacked the necessary written plan outlining the facility's responsibilities and actions during a waiver situation. No information about specific residents or their medical conditions was included in the findings.
Plan Of Correction
A plan for the role of the facility under a waiver declared by the Secretary of the Department is now present in the facility. The Maintenance Director/designee will ensure procedures to address the role of the facility under a waiver declared by the Secretary, in accordance with Section 1135 of the Act, in the provision of care at an alternative care site identified by emergency management officials is included in the Emergency Preparedness Plan. The Facility Administrator will ensure compliance by confirming the Emergency Preparedness Plan contains a written plan of the facility's role during a waiver declared by the Secretary of the Department of Health monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings.