Deficient Emergency Preparedness Plan and Risk Assessment Documentation
Penalty
Summary
The facility failed to maintain an Emergency Preparedness plan that was reviewed and updated annually, as required by regulations. Specifically, the facility did not provide evidence of a written, geographically specific risk assessment for hazards identified in their emergency plan. The plan was also required to utilize an all-hazards approach, including consideration of missing residents, but documentation supporting compliance with these requirements was not available for review. During the survey conducted on June 6, 2025, at 2:30 PM, the surveyor requested documentation of the facility-based and community-based risk assessment. The facility was unable to present the required documentation by the time of the survey exit. These findings were confirmed in interviews with both the Maintenance Director and the Corporate Operations Director during the record review process.
Plan Of Correction
E006 Element # 1: The facility emergency preparedness plan was updated using a geographically specific risk assessment. Element # 2: Current residents have the potential to be affected by the deficient practice. The facility Emergency Preparedness plan was reviewed, and necessary updates were made based on the geographically specific risk assessment. Element # 3: The policy, Emergency Operations Plan, was reviewed and deemed appropriate. The maintenance department and IDT were re-educated on the policy, Emergency Operations Plan, with emphasis on a geographically specific risk assessment. Element # 4: The Administrator and/or designee will conduct random audits of the emergency preparedness plan once a week for 1 month, then weekly for 1 month, and then monthly for 3 months to ensure substantial compliance with a geographically specific risk assessment. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025