Failure to Provide Alternate Communication Device Listed in Emergency Plan
Penalty
Summary
During a Fire & Life Safety re-licensure survey, surveyors reviewed the facility's Emergency Preparedness Program (EP) and found that the facility had listed satellite phones as an alternate means of communication in their emergency plan. However, when requested, the facility was unable to produce a satellite phone for inspection. This deficiency was identified through both record review and staff interview, where the absence of the listed communication device was confirmed. The Administrator acknowledged the findings during the interview and at the exit conference, confirming that the alternate communication method described in the EP was not available as required by federal regulations. The deficiency specifically relates to the facility's failure to ensure that the alternate means of communication, as outlined in their emergency preparedness plan, was present and accessible for inspection.
Plan Of Correction
Corrective Action for Affected Residents: The administrator added an updated list of primary and alternate means of communication. The facility does not use satellite phones. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: The administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure primary and alternate means of communication for the facility are listed. Monitoring/Quality Assurance: The Emergency Preparedness Manual will be reviewed annually, and findings will be submitted to QAPI.