Failure to Conduct and Document Semi-Annual Emergency Management Plan Testing
Summary
The facility failed to comply with Florida Administrative Code 59A-4.126 by not conducting and/or documenting the required semi-annual testing of its written, comprehensive emergency management plan for internal or external disasters or emergencies. During record review and staff interviews conducted between 11:30 AM and 3:00 PM with the Director of Facilities and the Administrator, surveyors requested documentation showing that semi-annual testing of the emergency management plan had been performed. The facility was unable to provide any such documentation, and both the Director of Facilities and the Administrator acknowledged that they failed to provide documentation showing that the semi-annual testing of the emergency management plan was performed. The deficiency was cited as a Class III violation and was noted as having the potential to affect all occupants of the facility in case of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report, and the deficiency pertained to facility-wide emergency preparedness processes rather than individual patient care events.
Plan Of Correction
Emergency Management Plan CFR(s): FAC 59A-4.126 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required. Emergency Management Plan K10531. On The Director of Facilities conducted a comprehensive emergency management drill to meet semi-annual testing requirements. Documentation of the drill and evaluation has been completed. 2. On Emergency preparedness documentation was reviewed by The Director of Facilities to ensure all required drills and evaluations are up to date. 3. A structured emergency preparedness calendar has been implemented to ensure semi-annual drills are conducted and documented in compliance with FAC 59A-4.126. 4. The Director of Facilities will present emergency preparedness documentation quarterly for compliance at Quality Assurance Performance Improvement (QAPI) meetings. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, [R] and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Penalty
Surveyors found that the facility did not comply with FAC 59A-4.126 requiring semiannual testing of its emergency management plan. During record review with the Maintenance Director and the Administrator, the facility was unable to produce documentation that the emergency management plan had been tested as required, either through actual events or planned drills. Both the Maintenance Director and the Administrator acknowledged the absence of documentation, and the deficiency was cited as a Class III violation with the potential to affect all occupants during a fire or other emergency.
Surveyors found that the facility's emergency power plan designated three cool zones for resident evacuation during power disruptions, but only a limited number of emergency power outlets were available in these areas. The Maintenance Director was unaware of this limitation, and the deficiency was cited due to the potential impact on residents reliant on electronic medical equipment.
Failure to Conduct and Document Semiannual Emergency Management Plan Testing
Penalty
Summary
The facility failed to comply with Florida Administrative Code 59A-4.126, which requires a written, comprehensive emergency management plan to be tested semiannually, either in response to an actual disaster/emergency or through a planned drill. During record review between 9:15 AM and 1:30 PM with the Maintenance Director and the Administrator, surveyors requested documentation of the semiannual testing of the emergency management plan. The facility was unable to provide any documentation showing that these required semiannual tests had been performed. The Maintenance Director and the Administrator acknowledged that the facility failed to provide documentation that the semiannual testing of the emergency management plan was performed. This deficiency was cited as a Class III violation and was noted as having the potential to affect all occupants in the facility in case of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report, and the deficiency centered solely on the lack of documented semiannual testing of the emergency management plan.
Plan Of Correction
The facility ran in-service drill for internal and external drills. Paperwork is in the log book in the maintenance director's books. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted. The administrator will conduct a three month check to verify completion of documentation.
Insufficient Emergency Power Outlets in Designated Cool Zones
Penalty
Summary
The facility failed to provide evidence of an adequate emergency power plan as required by Florida Administrative Code 59A-4.126. During a record review, the emergency power plan was found to describe three designated cool zones for resident evacuation during power disruptions. However, upon touring the facility, it was observed that the number of emergency power outlets available in these cool zones was limited: 10 receptacles in the C-Wing Dining room, 1 in the Main Dining room, and 3 in the Gym. This limited supply of emergency outlets was documented with photographic evidence. The Maintenance Director, when interviewed during the observations, acknowledged the findings and stated he was unaware of the limited number of emergency outlets in the designated cool zones. The deficiency was cited because the lack of sufficient emergency power outlets in these areas could impact the health and comfort of residents who rely on electronic medical equipment during a power disruption. No specific residents or their medical histories were mentioned in the report.
Plan Of Correction
No individual residents appear to be affected as no residents were noted. All residents reliant on electronic medical equipment have the potential to be affected. The DON/designee reviewed all residents to identify those reliant on electronic medical equipment on 07/11/2025, with 58 residents identified. The Administrator will develop and implement a policy and procedure regarding meeting the emergency needs of residents reliant on electronic medical equipment during a power outage by 07/25/2025. The Maintenance Director contacted a third-party vendor to add additional generator-powered outlets to the facility cool zones on 07/15/2025. A quote was received for the additional generator-powered outlet installation, approved and signed by the Administrator on 7/16/2025. Re-education was completed by the Administrator with the maintenance staff regarding Florida Administrative Code 59A-4.126 Emergency Environmental Control for Nursing Homes on 07/15/2025. The Administrator/Designee will audit the facility's Emergency Management Plan monthly for three months to ensure that the plan addresses residents reliant on electronic medical equipment. Results of the audits will be reviewed by the QAPI committee monthly for three months and randomly thereafter. Date of completion: 07/25/2025.
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