Deficient Emergency Preparedness Plan and Risk Assessment
Penalty
Summary
The facility failed to maintain an Emergency Preparedness plan that was reviewed and updated annually, as required. Specifically, the facility's emergency preparedness plan and hazard vulnerability assessment were not scored based on the percentage and probability of listed emergency events occurring. Additionally, the plan was not updated and was not site-specific to the facility. This deficiency was identified during a review of the facility's emergency preparedness documentation and was confirmed through interviews with the Maintenance Director and Administrator. The lack of a comprehensive, updated, and site-specific emergency preparedness plan could potentially affect all occupants and staff in the event of an area disaster.
Plan Of Correction
Element 1 - Upon identification of the finding, the Nursing Home Administrator reached out to its corporate organization to verify support in the event of a catastrophic event. This support was confirmed by the Vice President of Operations. Concurrently, the assistance of our Regional Environmental Services Coordinator was provided to assist Heartwood Lodge- Trinity Health in the construction of a comprehensive and compliant Hazard Vulnerability Assessment (HVA). Element 2 - The Emergency Preparedness Plan including the HVA will be constructed to include a scoring methodology based on the percentage and probability of each identified emergency event occurring within the facility's specific context on or before July 10th, 2025. Element 3 - The HVA will be revised to be entirely site-specific, incorporating unique aspects of the facility's layout, patient population, services provided, and surrounding environment. The Nursing Home Administrator, Environmental Services Director, and Director of Nursing will be reviewing and updating the Emergency Preparedness Plan and Hazard Vulnerability Assessment as required to maintain compliance on or before July 10th, 2025. Any identified issues will trigger retraining and/or corrective action. Element 4 - The QAPI Committee will be reviewing and updating Emergency Preparedness Plan and Hazard Vulnerability Assessment annually with a reminder recurrence online work order that occurs the first Monday of January. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.