Emergency Preparedness Plan Lacks Comprehensive Policies
Summary
The facility failed to ensure that its Emergency Preparedness Plan included comprehensive policies and procedures addressing the patient population, particularly persons at-risk, the types of services the facility could provide during an emergency, and the continuity of operations. This deficiency was identified during a document review conducted on May 1, 2025, at 8:15 a.m., which revealed that the plan did not adequately cover these critical areas, affecting the entire facility. An exit interview with the Maintenance Director on the same day at 10:30 a.m. confirmed the absence of necessary documentation in the Emergency Preparedness Plan. The lack of documentation indicates that the facility did not have a structured approach to managing emergencies, particularly concerning at-risk individuals and operational continuity, which is a requirement under §483.73(a)(3).
Plan Of Correction
The facility will ensure policies and procedures were in place addressing patient population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans, affecting the entire facility. Facility updated Emergency Preparedness Plan to include policies and procedures that addressed persons at-risk, affecting the entire facility.
Penalty
Surveyors found that the Emergency Preparedness Plan did not include required policies and procedures for addressing the resident population, including persons at-risk, available emergency services, and continuity of operations. Facility leadership confirmed the absence of this documentation, affecting the entire facility.
Surveyors found that the emergency preparedness plan did not include strategies for addressing the needs of at-risk or vulnerable residents. During review, the Administrator could not provide the required policy, and the facility did not submit the missing records when given the opportunity. This deficiency affected all residents.
The facility's Emergency Preparedness Plan was found lacking in policies and procedures addressing the patient population, particularly persons at-risk. A document review revealed the absence of details on services available during emergencies and continuity of operations. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility's Emergency Preparedness Plan was found lacking in essential components, such as addressing the resident population, particularly persons at-risk, and detailing the types of services available during emergencies. This deficiency was confirmed during a document review and an exit interview with the Administrator and Maintenance Director, highlighting a significant gap in the facility's emergency management strategy.
The Healthcare Center at White Horse Village was found deficient in its Emergency Preparedness Plan, failing to address the resident population, persons at-risk, and continuity of operations. This was confirmed during a survey and an exit interview with the Administrator and Maintenance Director.
Westgate Hills Rehabilitation and Nursing Center was found deficient in their Emergency Preparedness Plan, lacking policies and procedures for persons at-risk. This issue was identified during a document review and confirmed in interviews with the Administrator and Maintenance Director. A subsequent revisit showed the deficiency remained unaddressed.
Emergency Preparedness Plan Lacks Required Resident Population Policies
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included policies and procedures addressing the resident population, specifically persons at-risk, the types of services the facility could provide during an emergency, and continuity of operations such as delegations of authority and succession plans. This deficiency was identified through document review and interviews conducted on June 30, 2025, which revealed that the required documentation was not present in the facility's Emergency Preparedness Plan. During the exit interview with the Maintenance Supervisor and Director of Safety/Security, it was confirmed that the necessary documentation addressing these critical components was not available. The lack of these policies and procedures affected the entire facility, as the plan did not meet the regulatory requirements for addressing the needs of the resident population in emergency situations.
Plan Of Correction
Policy in place and will ensure that policy is present in emergency preparedness binder for future surveys.
Emergency Preparedness Plan Lacked Strategies for At-Risk Residents
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness plan that addressed the resident population, specifically the needs of at-risk or vulnerable residents. During a record review and interview with the Maintenance Director and Administrator, it was found that the emergency preparedness plan did not include strategies for addressing the needs of these populations. The Administrator was unable to explain why the relevant policy was missing from the emergency preparedness binder. The deficiency affected all 120 residents in the facility. The facility was given an opportunity to submit the missing records by a specified deadline, but no records were received by the regulatory agency. The lack of documentation and planning for at-risk or vulnerable residents was directly observed during the survey process.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/08/2025, the Emergency Preparedness Plan was revised to include specific strategies addressing the needs of at-risk and vulnerable populations such as residents with cognitive impairments, limited mobility, and complex medical needs. 2. Identification of other residents having the potential to be affected was accomplished by: On 5/12/2025, the Interdisciplinary Team reviewed all resident records to determine which individuals were considered at-risk during an emergency. All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/25, the Emergency Plan was updated to include a section for identifying vulnerable residents, and care protocols were developed for each type of identified risk (e.g., evacuation assistance, medication needs). 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of the Emergency Preparedness Plan. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.
Emergency Preparedness Plan Lacks Key Components
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included comprehensive policies and procedures addressing the patient population, specifically focusing on persons at-risk. During a document review conducted on February 6, 2025, it was revealed that the plan lacked necessary details regarding the types of services the facility could provide in an emergency and the continuity of operations, including delegations of authority and succession plans. An exit interview with the Facility Administrator and Maintenance Director confirmed the absence of documentation addressing these critical areas. This deficiency affects the entire facility, as it does not adequately prepare for the needs of its resident population in emergency situations.
Plan Of Correction
Adopted Policy and procedure for addressing patient population, including, but not limited to, persons at risk into facility's emergency preparedness plan by 3/21/2025. A review of policies and procedures will be conducted on an annual basis by the Administrator or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.
Emergency Preparedness Plan Lacks Key Components
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included comprehensive policies and procedures addressing the resident population, particularly persons at-risk, the types of services the facility could provide during an emergency, and the continuity of operations, including delegations of authority and succession plans. This deficiency was identified during a document review conducted on January 23, 2025, at 8:30 a.m., which revealed that the plan did not adequately cover these critical areas. During an exit interview with the Administrator and Maintenance Director on the same day at 11:45 a.m., it was confirmed that there was a lack of documentation supporting the inclusion of these necessary components in the Emergency Preparedness Plan. This oversight affects the entire facility, as it leaves the facility unprepared to effectively manage emergencies, particularly concerning the care and safety of at-risk residents.
Plan Of Correction
1. Policy on person at risk was reviewed and education done with staff. 2. Policy available in Emergency Preparedness binder.
Deficiency in Emergency Preparedness Plan
Penalty
Summary
The Healthcare Center at White Horse Village was found to have deficiencies in its Emergency Preparedness Plan during a survey conducted on January 13, 2025. The facility failed to ensure that its policies and procedures adequately addressed the resident population, including persons at-risk, the type of services the facility could provide in an emergency, and the continuity of operations, including delegations of authority and succession plans. This deficiency was identified through a document review and confirmed during an exit interview with the Administrator and the Maintenance Director. The survey revealed that the facility's Emergency Preparedness Plan did not include the necessary documentation to address these critical areas, affecting the entire facility. The lack of documentation was confirmed during the exit interview, indicating a failure to comply with the requirements set forth in 42 CFR 483.73(a)(3). This deficiency has the potential for minimal harm, as it pertains to the facility's ability to effectively manage emergencies and ensure the safety and well-being of its residents.
Plan Of Correction
Facility established policy to define the patient population served, patients at risk and the types of services that the community can provide in an emergency to ensure continuity. The Senior Director of Property and Facilities will ensure the Emergency Operations Manual and related policies are reviewed on an annual basis. Results of review will be submitted by The Senior Director of Property and Facilities to the Quality Assurance and Performance Improvement Committee on an annual basis.
Deficiency in Emergency Preparedness Plan at Westgate Hills
Penalty
Summary
Westgate Hills Rehabilitation and Nursing Center was found to have deficiencies in their Emergency Preparedness Plan during a revisit survey. The facility failed to include policies and procedures addressing the patient population, specifically persons at-risk, in their emergency preparedness documentation. This deficiency was identified during a document review on November 20, 2024, and confirmed during an exit interview with the Administrator and the Maintenance Director. A subsequent onsite revisit conducted on January 8, 2025, revealed that the facility still had not addressed the missing documentation in their Emergency Preparedness Plan. The plan continued to lack policies and procedures for persons at-risk, affecting the entire facility. This was again confirmed during an exit interview with the Administrator and the Regional Maintenance Director.
Plan Of Correction
Plan of Correction for TAG E0007: Emergency Preparedness Plan - Patient Population and Continuity of Operations 1. Deficiency: Based on document review and interview, the facility failed to ensure policies and procedures were in place addressing patient population, including but not limited to persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegation of authority and succession plans, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed the Facility's Emergency Preparedness Plan did not include policies and procedures addressing persons at-risk. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the missing documentation. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected in the event of an emergency where these provisions are required. 2. Corrective Action: The facility will update its Emergency Preparedness Plan to include: - Policies and procedures addressing persons at-risk within the patient population. - A clear description of the types of services the facility is able to provide in the event of an emergency. - Continuity of operations, including delegation of authority and succession plans for key personnel to ensure continued operation during an emergency. 3. Monitoring: The Emergency Preparedness Plan will be reviewed annually to ensure it includes all necessary policies and procedures for the patient population, including those at risk, and for continuity of operations. Any updates or changes will be presented to the Quality Assessment and Assurance Committee for review and approval. 4. Timeline: The Emergency Preparedness Plan will be updated by 01/28/25, with an annual review thereafter.
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