Failure to Maintain Effective Compliance and Ethics Program; Falsified Emergency Management Plan Approval
Penalty
Summary
The facility failed to maintain an effective compliance and ethics program, as evidenced by the submission of a falsified Emergency Management Plan approval letter during a Life Safety Code annual survey revisit. When surveyors requested the most recent Emergency Management Plan approved by the County, the administrator provided a document dated 05/08/25. Upon review and comparison with documentation from the County Emergency Management Director, surveyors determined that the approval letter was falsified. During an interview, the administrator was unable to confirm the existence of a current compliance and ethics program, initially stating uncertainty and referencing a previous program with a Human Resources representative as the compliance officer. She later stated that she, as the administrator, was responsible for compliance, as indicated in her job description. The facility's policies and employee handbook included general statements about ethical conduct and compliance but did not demonstrate the presence of an effective compliance and ethics program as required.