Missing Staff Contact Information in Emergency Preparedness Plan
Penalty
Summary
Surveyors determined that the facility failed to include the names and contact information of staff within the physical copy of the emergency preparedness plan. During a document review, it was found that this required information was missing from the plan, which is intended to serve the entire component of the facility. The absence of this information was confirmed during an interview with the Director of Maintenance. This deficiency was identified during a Medicare/Medicaid Recertification Survey. The survey specifically noted that the physical emergency preparedness plan did not contain the necessary staff contact details as mandated by federal regulations. No information about residents or their medical conditions was included in the findings.
Plan Of Correction
1. The name/contact list was located in the original EOP binder. 2. The EOP phone list will be updated as needed or should personnel change. 3. The EOP is reviewed on an annual basis and the contact list will be verified as current. 4. The Facilities Director will verify monthly that the list remains current and document on the audit sheet. This will be maintained in the EOP and reported to the Safety Committee on a monthly basis. 5. The completion date is 9/25/25.