Failure to Annually Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to maintain its emergency preparedness plan (EPP) in accordance with federal regulations, which require the plan to be reviewed and updated at least annually. During a record review and interview with staff, surveyors requested the EPP and found that the most recent update was dated 11/15/23. Staff confirmed that the last review of the EPP occurred in 2023, and no updated version was available for the current year. This deficiency was identified during a survey on 6/9/25, where it was determined that the EPP had not been reviewed or updated within the required annual timeframe. The lack of an updated EPP could impact the facility's ability to ensure proper planning and preparation for the health and safety of all 90 residents, as the plan may not reflect current risks or procedures.
Plan Of Correction
The facility recognizes the importance of maintaining the emergency preparedness plan. The facility will continue to maintain the emergency preparedness plan every year by reviewing and updating the plan annually. The facility shall update the EPP on June 26, 2025, during the QA Committee meeting. The facility shall include the EPP review and update as part of the facility's annual review for all facility Policies and Procedures, to be conducted in January 2026 and then each consecutive year in the following January. The update will be communicated to staff during the all-staff meeting scheduled for June 26, 2025, coordinated by the Administrator and facility Environmental Services Supervisor. Further issues regarding the EPP annual update and approval will be received during the QA process and brought to the QAPI Committee for review. The Environmental Services Supervisor, Administrator, and QA Manager will be responsible to ensure ongoing compliance.