Failure to Submit Valid Emergency Management Plan and Falsification of Documentation
Penalty
Summary
The facility failed to ensure proper administration and use of resources to maintain the highest practicable physical wellbeing of each resident by not submitting a valid Emergency Management Plan to the County Emergency Management Office as required. During a Life Safety Code annual survey revisit, surveyors requested the most recent Emergency Management Plan, and the administrator provided a document dated 05/08/25. Upon review, it was determined that this document was falsified, as confirmed by the County Emergency Management Director, who stated that no plan had been submitted for review and that the form provided used an outdated logo, further indicating its inauthenticity. The administrator acknowledged responsibility for submitting the Emergency Management Plan and for the contents of the Emergency Plan binder, which was kept in her office but also accessible to the maintenance director. Despite this responsibility, she stated she did not know the origin of the falsified letter and had not contacted the County Emergency Management Director to submit the required plan since the previous survey or revisit. The facility's Executive Director position description confirms the administrator's accountability for compliance with all state and federal regulations, including the submission and maintenance of required emergency documentation.