Failure to Document All-Hazards Risk Assessment
Summary
The facility failed to meet emergency preparedness guidelines as required by regulations. During a document review on April 8, 2025, it was found that the facility did not have a documented risk assessment that utilized an all-hazards approach. This is a critical component of the emergency preparedness plan that should be reviewed and updated at least annually for long-term care facilities. An interview with the maintenance director on the same day confirmed the absence of the necessary documentation. The lack of a documented risk assessment indicates that the facility did not comply with the requirement to develop and maintain an emergency preparedness plan based on a facility-based and community-based risk assessment, which is essential for addressing potential emergency events.
Plan Of Correction
Risk assessment was completed for the facility in our company's electronic system. The facility printed the assessment and has placed it in our life safety binder. The maintenance director and administrator will ensure that when the risk assessment is completed, it is printed and placed in the life safety binder at the time of completion.
Penalty
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors found that the facility did not have a written Emergency Preparedness Plan that included an annually updated facility-based and community-based risk assessment using an all-hazards approach. This deficiency was confirmed through document review and interviews with facility leadership.
Kadima Rehabilitation & Nursing at Lititz failed to provide an updated all-hazards risk assessment as required for emergency preparedness. During a survey, document review and interviews with the DON and Director of Maintenance confirmed that the facility did not have current documentation of this assessment, affecting the entire facility.
Schuylkill Center did not provide an updated all-hazards risk assessment as required, with both the Administrator and Maintenance Director confirming the absence of this documentation during survey review.
The facility did not maintain an updated, site-specific emergency preparedness plan, and its hazard vulnerability assessment lacked scoring based on the likelihood of emergency events. This deficiency was confirmed through documentation review and interviews with facility leadership.
The facility did not maintain an Emergency Preparedness plan that was reviewed and updated annually, and failed to provide documentation of a written, geographically specific risk assessment for hazards identified in the emergency plan. Required documentation supporting compliance with an all-hazards approach, including missing residents, was not available for review, as confirmed by the Maintenance Director and Corporate Operations Director.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Emergency Preparedness Plan with Required Risk Assessment
Penalty
Summary
The facility failed to provide a written Emergency Preparedness (EP) Plan that included a facility-based and community-based risk assessment, as required by regulations. During a document review and interview conducted on July 7, 2025, it was found that the EP plan did not contain an annually updated risk assessment utilizing an all-hazards approach. This assessment is necessary to identify and address potential emergency events, including missing residents, as part of the facility's preparedness planning. Interviews with the Facility Administrator and Maintenance Director confirmed the absence of the required documentation in the EP plan. The deficiency was identified through both the review of the facility's emergency preparedness documentation and direct confirmation from facility leadership.
Plan Of Correction
A written Emergency Preparedness Plan that includes a facility-based and community-based risk assessment is now present in the facility. The Maintenance Director/designee will complete a check of the written Emergency Preparedness Plan to ensure it includes an annually updated facility-based and community-based risk assessment, utilizing an all-hazards approach. To ensure compliance, this check will be performed monthly for three months. Findings will be reviewed at monthly Quality Assurance Meetings.
Failure to Maintain Updated All-Hazards Risk Assessment
Penalty
Summary
Kadima Rehabilitation & Nursing at Lititz was found to be non-compliant with federal emergency preparedness requirements during a Medicare/Medicaid Recertification Survey. Specifically, the facility failed to provide an updated all-hazards risk assessment as required by regulation. This assessment is a critical component of the emergency preparedness plan and must be reviewed and updated at least annually for LTC facilities. The deficiency was identified through document review, which revealed the absence of an updated risk assessment for the facility. During the exit conference, both the Director of Nursing and the Director of Maintenance confirmed that they could not provide documentation of an updated all-hazards risk assessment. The lack of this documentation affected the entire facility component, as the risk assessment is necessary to identify and plan for potential emergency events, including missing residents and other hazards relevant to the facility's operation.
Plan Of Correction
1. We cannot retroactively correct. 2. The Hazard Risk Assessment will be updated. 3. Administration will be educated on the need for updating the Hazard Risk Assessment. 4. The EPP committee will review the updated risk assessment.
Failure to Maintain Updated All-Hazards Risk Assessment
Penalty
Summary
Schuylkill Center was found to be noncompliant with federal emergency preparedness requirements following an Emergency Preparedness Survey. The facility failed to provide an updated all-hazards risk assessment, which is required to be reviewed and updated at least annually. During document review, surveyors were unable to obtain documentation of a current all-hazards risk assessment for the facility. At the time of the exit conference, both the Administrator and Maintenance Director confirmed that they could not provide an updated all-hazards risk assessment. This deficiency affected the entire facility component and was based solely on the lack of required documentation. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Plan Of Correction
The facility will continue to provide an updated all hazards risk assessment for the facility. 1. The facility utilizes the Kaiser Permanente Hazard Vulnerability Assessment Tool, which was last updated at the time of annual manual approvals on 1/17/2025. This tool will be updated at least quarterly, or as needed, and used to identify and update the facility's Emergency Preparedness plan. The Hazards Risk Assessment will be filed in all copies of the Emergency Preparedness plan. 2. The Maintenance Director or designee will audit the Hazard Vulnerability Assessment tool at least semi-annually to confirm that updates are filed in all copies of the Emergency Preparedness plan. Results of the audits will be reviewed at least semi-annually with the QAPI Committee, including any revisions required to the Facility Emergency Preparedness plan as a result of the assessment. Date of Correction is 7/30/2025.
Deficient Emergency Preparedness Plan and Risk Assessment
Penalty
Summary
The facility failed to maintain an Emergency Preparedness plan that was reviewed and updated annually, as required. Specifically, the facility's emergency preparedness plan and hazard vulnerability assessment were not scored based on the percentage and probability of listed emergency events occurring. Additionally, the plan was not updated and was not site-specific to the facility. This deficiency was identified during a review of the facility's emergency preparedness documentation and was confirmed through interviews with the Maintenance Director and Administrator. The lack of a comprehensive, updated, and site-specific emergency preparedness plan could potentially affect all occupants and staff in the event of an area disaster.
Plan Of Correction
Element 1 - Upon identification of the finding, the Nursing Home Administrator reached out to its corporate organization to verify support in the event of a catastrophic event. This support was confirmed by the Vice President of Operations. Concurrently, the assistance of our Regional Environmental Services Coordinator was provided to assist Heartwood Lodge- Trinity Health in the construction of a comprehensive and compliant Hazard Vulnerability Assessment (HVA). Element 2 - The Emergency Preparedness Plan including the HVA will be constructed to include a scoring methodology based on the percentage and probability of each identified emergency event occurring within the facility's specific context on or before July 10th, 2025. Element 3 - The HVA will be revised to be entirely site-specific, incorporating unique aspects of the facility's layout, patient population, services provided, and surrounding environment. The Nursing Home Administrator, Environmental Services Director, and Director of Nursing will be reviewing and updating the Emergency Preparedness Plan and Hazard Vulnerability Assessment as required to maintain compliance on or before July 10th, 2025. Any identified issues will trigger retraining and/or corrective action. Element 4 - The QAPI Committee will be reviewing and updating Emergency Preparedness Plan and Hazard Vulnerability Assessment annually with a reminder recurrence online work order that occurs the first Monday of January. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.
Deficient Emergency Preparedness Plan and Risk Assessment Documentation
Penalty
Summary
The facility failed to maintain an Emergency Preparedness plan that was reviewed and updated annually, as required by regulations. Specifically, the facility did not provide evidence of a written, geographically specific risk assessment for hazards identified in their emergency plan. The plan was also required to utilize an all-hazards approach, including consideration of missing residents, but documentation supporting compliance with these requirements was not available for review. During the survey conducted on June 6, 2025, at 2:30 PM, the surveyor requested documentation of the facility-based and community-based risk assessment. The facility was unable to present the required documentation by the time of the survey exit. These findings were confirmed in interviews with both the Maintenance Director and the Corporate Operations Director during the record review process.
Plan Of Correction
E006 Element # 1: The facility emergency preparedness plan was updated using a geographically specific risk assessment. Element # 2: Current residents have the potential to be affected by the deficient practice. The facility Emergency Preparedness plan was reviewed, and necessary updates were made based on the geographically specific risk assessment. Element # 3: The policy, Emergency Operations Plan, was reviewed and deemed appropriate. The maintenance department and IDT were re-educated on the policy, Emergency Operations Plan, with emphasis on a geographically specific risk assessment. Element # 4: The Administrator and/or designee will conduct random audits of the emergency preparedness plan once a week for 1 month, then weekly for 1 month, and then monthly for 3 months to ensure substantial compliance with a geographically specific risk assessment. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
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