Failure to Conduct and Document Semi-Annual Emergency Management Plan Testing
Penalty
Summary
The facility failed to comply with Florida Administrative Code 59A-4.126 by not conducting and/or documenting the required semi-annual testing of its written, comprehensive emergency management plan for internal or external disasters or emergencies. During record review and staff interviews conducted between 11:30 AM and 3:00 PM with the Director of Facilities and the Administrator, surveyors requested documentation showing that semi-annual testing of the emergency management plan had been performed. The facility was unable to provide any such documentation, and both the Director of Facilities and the Administrator acknowledged that they failed to provide documentation showing that the semi-annual testing of the emergency management plan was performed. The deficiency was cited as a Class III violation and was noted as having the potential to affect all occupants of the facility in case of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report, and the deficiency pertained to facility-wide emergency preparedness processes rather than individual patient care events.
Plan Of Correction
Emergency Management Plan CFR(s): FAC 59A-4.126 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required. Emergency Management Plan K10531. On The Director of Facilities conducted a comprehensive emergency management drill to meet semi-annual testing requirements. Documentation of the drill and evaluation has been completed. 2. On Emergency preparedness documentation was reviewed by The Director of Facilities to ensure all required drills and evaluations are up to date. 3. A structured emergency preparedness calendar has been implemented to ensure semi-annual drills are conducted and documented in compliance with FAC 59A-4.126. 4. The Director of Facilities will present emergency preparedness documentation quarterly for compliance at Quality Assurance Performance Improvement (QAPI) meetings. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, [R] and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
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