Emergency Preparedness Plan Lacks Shelter-in-Place Procedures
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a review of their Disaster Manual Disaster Plan, conducted in conjunction with a Life Safety Code survey. The plan, which was last reviewed on 10/16/24, lacked policies and procedures for providing a means to shelter in place for residents, staff, and volunteers who remained in the facility. 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, and acknowledged that an updated plan was being developed but had not yet been implemented.
Plan Of Correction
Plan of Correction: Approved December 29, 2024 1. Administrator reviewed the current Emergency Preparedness plan and updated EPP on 12/29/2024 to include policy and procedure for Sheltering in place. 2. All Residents are at risk for deficient practice for not having sheltering in place policy procedure addressed in the EPP. 3. All staff were trained on the emergency preparedness plan which policy and procedure on sheltering in place and steps to follow in case of emergency by RN Educator. Education was completed for all staff on 1/24/2024. 4. The HVA will be reviewed quarterly in the QAPI meeting to ensure updated EPP is reviewed and updated on any new changes. Any deficient practices will be corrected and further reviewed at QAPI Meeting. Person Responsible: Administrator
Penalty
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