Failure to Annually Update Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain compliance with federal regulations requiring an annually reviewed and updated emergency preparedness communication plan. During a record review and interview with staff, surveyors found that the emergency preparedness plan (EPP) had not been updated since 11/15/23, and staff confirmed that the last review occurred in 2023. As a result, the facility did not have an up-to-date communication plan as required, affecting the planning and preparation for the health and safety of all 90 residents. No additional details regarding the medical history or condition of the residents at the time of the deficiency were provided in the report.
Plan Of Correction
The facility recognizes the importance of maintaining an updated communication plan. The facility shall continue to maintain an updated communication plan and review it annually. The facility shall update the emergency preparedness communication plan by June 26, 2025, during the QA Committee meeting. The communication plan shall be included when the facility reviews the emergency preparedness plan annually in January 2026 and each year consecutively in the following January. Further issues regarding the facility's development of a communication plan as part of the emergency preparedness plan 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 DON shall be responsible for monitoring and ongoing compliance.