Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, as required by federal regulations. During an interview and document review, it was found that the Emergency Preparedness Plan had not been reviewed or updated within the required timeframe. This deficiency was identified through documentation review and confirmed during interviews with the Maintenance Supervisor and Director of Safety/Security. No documentation was available to demonstrate that the annual review and update of the Emergency Preparedness Plan had occurred. The lack of updated records affected the entire facility, as the plan is intended to address emergency preparedness for all residents and staff. There were no specific residents or patient medical histories mentioned in relation to this deficiency.