Emergency Preparedness Plan Lacks Communication Method
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a review of their Disaster Manual Disaster Plan. The plan, which was last reviewed on 10/16/24, lacked documentation on the method for sharing information with residents and their families or representatives. This deficiency affected the entire first floor, including three resident units, the second-floor administration area, and the basement. During an interview, the Administrator confirmed that the Disaster Manual Disaster Plan was the current emergency preparedness plan in use since the facility's inception in 2024. However, the Administrator also acknowledged that an updated Emergency Preparedness Plan was being developed but had not yet been implemented.
Plan Of Correction
Plan of Correction: Approved December 29, 2024 1. Administrator reviewed current EPP and updated EPP on items not included. The EPP and Pandemic Plan were updated to facility's website on 1/17/2025. 2. All Residents are at risk for deficient practice for not having updated EPP posted on the website. 3. All staff and residents were notified that the EPP is posted on the website on 1/17/2025 by written correspondence by Administrator. 4. The EPP plan will be reviewed quarterly in the QAPI meeting to ensure updated EPP is available via website for staff, residents, and family. Any deficient practices will be corrected and further reviewed at QAPI Meeting. Person Responsible: Administrator
Penalty
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