Deficiency in Emergency Preparedness Plan
Summary
The facility was found to be deficient in developing an Emergency Preparedness Plan that included the required names and contact information. During a document review on January 21, 2025, it was revealed that the facility's plan did not contain or reference the necessary contact information for staff, entities providing services under arrangement, patients' physicians, other facilities, and volunteers. This omission was identified as a failure to comply with the regulatory requirements for emergency preparedness communication plans. An exit interview with the Executive Director of Construction and Ancillary Services confirmed that while a contact information template was included in the Emergency Preparedness Plan, it lacked the specific names and contact information of facility-based individuals. This deficiency indicates that the facility did not meet the mandated standards for maintaining an up-to-date and comprehensive communication plan, which is essential for effective emergency preparedness.
Plan Of Correction
1) Updated communication plan and list completed by facility. 2) ED of construction to inservice supervisor of plant OPS on policy and procedure of keeping communications plan and list up to date. 3) ED of construction or delegate to complete audits 3x per week x 4 weeks to ensure communication plan and list are completed in accordance with policies and procedures. Audits findings will be submitted to QAPI committee monthly for further reviews and recommendations as needed. Further audits frequently will be determined based on the outcome of the survey.
Penalty
Surveyors identified that the facility's Emergency Preparedness Program lacked required contact information for all staff and residents' physicians in its communication plan. The Administrator acknowledged these omissions during the review, and the findings were discussed with facility leadership.
Surveyors found that the emergency preparedness plan did not include required staff names and contact information, as confirmed by document review and an interview with the Director of Maintenance.
The facility's Emergency Preparedness Program was found deficient as it included outdated staff information, risking resident safety during emergencies due to potential lack of medical and support staffing.
The facility's Emergency Preparedness Plan was found deficient due to missing updated names and contact information for staff and residents' physicians. This was confirmed during interviews with the Facility Administrator and Maintenance Director.
Cedarwood Rehabilitation and Healthcare Center's Emergency Preparedness Plan was found deficient due to missing updated names and contact information for staff and resident physicians. This was confirmed by the facility's leadership during a survey, indicating a lapse in maintaining essential documentation for emergency situations.
Riverside Health and Rehab Center was found deficient in its Emergency Preparedness Plan for not including updated and accurate contact information for residents and their physicians. This was confirmed by the Facility Administrator and Maintenance Director during a survey, highlighting a failure to comply with 42 CFR 483.73 requirements.
Incomplete Emergency Preparedness Communication Plan
Penalty
Summary
During a review of the facility's Emergency Preparedness Program (EP), surveyors found that the facility did not maintain a complete communication plan as required by federal regulations. Specifically, the communication plan was missing contact information for all staff members and for residents' physicians. This omission was identified during a record review conducted with the facility Administrator. The deficiency was confirmed through both documentation review and an interview with the Administrator, who acknowledged the absence of the required contact information in the EP. The findings were also discussed with the Regional Maintenance Director during the exit conference. No information was provided in the report regarding specific residents or their medical conditions at the time of the deficiency. The focus of the deficiency was solely on the incomplete communication plan within the facility's emergency preparedness documentation.
Plan Of Correction
Corrective Action for Affected Residents: The Administrator added a phone list of all employees and primary physicians that attend the facility. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: Administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure all contacts are current. Monitoring / Quality Assurance: Emergency Preparedness Manual will be reviewed annually and findings submitted to QAPI. E0030 Corrective Action for Affected Residents: The Administrator added a phone list of all employees and primary physicians that attend the facility. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: Administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure all contacts are current. Monitoring / Quality Assurance: Emergency Preparedness Manual will be reviewed annually and findings submitted to QAPI. E0030
Missing Staff Contact Information in Emergency Preparedness Plan
Penalty
Summary
Surveyors determined that the facility failed to include the names and contact information of staff within the physical copy of the emergency preparedness plan. During a document review, it was found that this required information was missing from the plan, which is intended to serve the entire component of the facility. The absence of this information was confirmed during an interview with the Director of Maintenance. This deficiency was identified during a Medicare/Medicaid Recertification Survey. The survey specifically noted that the physical emergency preparedness plan did not contain the necessary staff contact details as mandated by federal regulations. No information about residents or their medical conditions was included in the findings.
Plan Of Correction
1. The name/contact list was located in the original EOP binder. 2. The EOP phone list will be updated as needed or should personnel change. 3. The EOP is reviewed on an annual basis and the contact list will be verified as current. 4. The Facilities Director will verify monthly that the list remains current and document on the audit sheet. This will be maintained in the EOP and reported to the Safety Committee on a monthly basis. 5. The completion date is 9/25/25.
Deficient Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain an up-to-date communication plan as part of their Emergency Preparedness Program (EP). During a review conducted on February 11, 2025, it was found that the list of staff included individuals who no longer worked at the facility. This deficiency was identified through a record review and interview process, where the Administrator acknowledged that the plan had been reviewed through the Quality Assurance and Performance Improvement (QAPI) process but still required several updates, including current staffing information. The absence of an accurate communication plan, particularly in the context of an emergency, poses a risk to residents as it could lead to a lack of medical and support staffing during a transfer to other facilities. The deficiency highlights the facility's failure to ensure that the communication plan includes the necessary names and contact information of staff and residents' physicians, which is crucial for effective emergency response and resident safety.
Plan Of Correction
1. Name and contact information was updated to reflect current contacts and employees. 2. Audit of E tags was conducted, and any incorrect findings were corrected. 3. Education provided for E030. 4. Audit for compliance for E30 will be completed by administrator or designee monthly and reported to QAPI for one quarter.
Deficiency in Emergency Preparedness Plan
Penalty
Summary
The facility's Emergency Preparedness (EP) Plan was found to be deficient during a review conducted on February 6, 2025. The review revealed that the EP Plan did not include updated and accurate names and contact information for the staff and residents' physicians. This omission was identified during an interview and documentation review at 9:15 a.m. The deficiency was confirmed in a subsequent interview with the Facility Administrator and Maintenance Director at 1:00 p.m. on the same day. The lack of updated contact information in the EP Plan indicates a failure to comply with the requirement to maintain a comprehensive communication plan, which is essential for effective emergency preparedness.
Plan Of Correction
Facility emergency preparedness plan will be updated by 3/21/2025 for accurate names and contact information for staff and resident physicians. A review of the staff and resident physicians will be conducted monthly by the Maintenance director or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.
Deficiency in Emergency Preparedness Plan
Penalty
Summary
Cedarwood Rehabilitation and Healthcare Center was found to have deficiencies in its Emergency Preparedness (EP) Plan during a survey conducted on January 14, 2025. The facility failed to include updated and accurate names and contact information for its staff and resident physicians, which is a requirement under 42 CFR 483.73. This deficiency was identified through a review of the facility's EP Plan and confirmed during interviews with the Director of Nursing and the Maintenance Director. The survey revealed that the EP Plan did not meet the necessary standards as it lacked essential contact details, which are crucial for effective communication during emergencies. The absence of this information was confirmed by the facility's leadership, indicating a lapse in maintaining the required documentation for emergency preparedness. This oversight has the potential for minimal harm, as it could impede timely communication and coordination in emergency situations.
Plan Of Correction
1. The facility EP plan has been updated to accurately reflect the proper staff and physician contact information. 2. Maintenance director or designee will verify it is updated if information changes. 3. Nursing home administrator or designee will re-educate the maintenance director on accurately and timely updating the EP plan as contact information changes. 4. Maintenance director or designee will audit the EP plan monthly for the next three months to verify contact information is accurate. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed. Date of compliance will be 2/18/2025.
Deficiency in Emergency Preparedness Plan at Riverside Health and Rehab Center
Penalty
Summary
Riverside Health and Rehab Center was found to have deficiencies in its Emergency Preparedness (EP) Plan during a survey conducted on December 30, 2024. The facility failed to include updated and accurate names and contact information for residents and their physicians in the EP Plan. This deficiency was identified through an interview and documentation review conducted at 8:45 a.m. on the same day. The Facility Administrator and Maintenance Director confirmed during an interview at 1:30 p.m. that the EP Communication Plan lacked the necessary accurate contact information for residents and their physicians. This omission in the communication plan is a violation of the requirements set forth in 42 CFR 483.73, which mandates that such information be included and maintained in the facility's emergency preparedness communication plan.
Plan Of Correction
NHA/Designee will educate the Maintenance Director/Designee on the Emergency Preparedness Plan requirements regarding Names and Contact Information. The current resident roster and physicians names and contact information will be put in the EPP binder and be updated weekly by the Receptionist/Designee. NHA/Designee will audit the EPP names and contacts on weekly x 4 weeks.
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