Failure to Annually Update Emergency Preparedness Plan Policies and Procedures
Penalty
Summary
The facility failed to maintain and update its emergency preparedness plan (EPP) policies and procedures as required. During a record review and interview with staff, it was found that the EPP had not been updated annually, with the last documented review occurring in November 2023. Staff confirmed that the most recent review date was in 2023, indicating that the required annual update had not been completed. This deficiency was identified during a survey in which the EPP was specifically requested and examined. The lack of an updated EPP could result in the absence of proper planning and preparation to protect the health and safety of all 90 residents in the facility. No additional details about individual residents or their medical conditions were provided in the report.
Plan Of Correction
The facility recognizes the importance of maintaining the emergency preparedness plan (EPP). The facility shall continue to ensure the emergency preparedness plan has updated policies and procedures. The facility shall update the emergency preparedness plan policies and procedures by June 26, 2025, during the QA Committee meeting. The facility shall include the reviewed and updated emergency preparedness plan policies and procedures as part of the annual review for all facility policies and procedures to be conducted in January 2026, and then each consecutive year in the following January. Further issues regarding the facility's emergency preparedness plan's policies and procedures shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, and Director of Nursing shall be responsible to ensure ongoing compliance. This page is purposefully left blank.