Deficiency in Emergency Preparedness Plan Review
Summary
Chapel Manor was found to have a deficiency related to its Emergency Preparedness Plan during an Emergency Preparedness Survey conducted on December 23, 2024. The survey revealed that the facility failed to review and update its Emergency Preparedness Plan at least annually, as required by federal regulations under 42 CFR 483.73(a). This deficiency was identified through a documentation review conducted at 8:30 a.m. on the day of the survey. An exit interview with the Assistant Administrator and the Maintenance Director confirmed that the Emergency Preparedness Plan had not been reviewed and updated as required. This oversight affects the entire facility, as the plan is a critical component of the facility's ability to respond effectively to emergencies. The lack of annual review and updates to the plan constitutes a failure to comply with the necessary emergency preparedness requirements, which are designed to ensure the safety and well-being of all residents and staff in the facility.
Plan Of Correction
Emergency preparedness plan has been reviewed and updated for 2024-2025. Maintenance Dir/designee will re-educate maintenance staff on timely updates and to keep the EPP book in one location. NHA/designee will complete quarterly audits to ensure EPP manual is updated and its proper location. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.
Penalty
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that the facility did not have documentation verifying that its emergency preparedness plan was reviewed by the EPP committee within the required annual timeframe. This was confirmed by both the DON and Director of Maintenance during the exit conference.
Surveyors found that the facility did not review or update its Emergency Preparedness Plan within the required annual timeframe. Documentation confirming the annual review was not available, and this deficiency was confirmed during interviews with the Maintenance Supervisor and Director of Safety/Security.
Surveyors found that the facility did not review or update its emergency preparedness plan within the required annual timeframe, as the last update was in 2023. Staff confirmed the absence of a current plan, affecting planning for all residents.
The facility did not review or update its Emergency Operations Plan within the required annual timeframe, as the last update was over a year prior. The Director of Plant Operations believed the review was required every two years, following hospital guidelines, rather than annually as required for LTC facilities. This deficiency affected all patients in the facility.
The facility did not review and update its Emergency Preparedness Plan annually, as required. A document review revealed this deficiency, and the Maintenance Director confirmed the lack of documentation.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Lack of Annual Review Documentation for Emergency Preparedness Plan
Penalty
Summary
The facility failed to provide documentation verifying that its emergency preparedness plan was reviewed within the previous twelve months. During a document review on July 1, 2025, surveyors were unable to locate evidence that the emergency preparedness plan had been reviewed by the Emergency Preparedness Plan (EPP) committee as required. An interview conducted at the exit conference with the Director of Nursing and the Director of Maintenance confirmed the absence of documentation showing that the emergency preparedness plan had been reviewed in the past year. No additional information regarding specific residents or patient conditions was provided in the report.
Plan Of Correction
1. We can not retroactively correct. 2. The Emergency Preparedness plan will be reviewed by the EPP committee. 3. The Environmental Services Director will be educated on the need for EPP review. 4. The EPP plan review will be audited yearly in July.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, as required by federal regulations. During an interview and document review, it was found that the Emergency Preparedness Plan had not been reviewed or updated within the required timeframe. This deficiency was identified through documentation review and confirmed during interviews with the Maintenance Supervisor and Director of Safety/Security. No documentation was available to demonstrate that the annual review and update of the Emergency Preparedness Plan had occurred. The lack of updated records affected the entire facility, as the plan is intended to address emergency preparedness for all residents and staff. There were no specific residents or patient medical histories mentioned in relation to this deficiency.
Failure to Annually Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to maintain its emergency preparedness plan (EPP) in accordance with federal regulations, which require the plan to be reviewed and updated at least annually. During a record review and interview with staff, surveyors requested the EPP and found that the most recent update was dated 11/15/23. Staff confirmed that the last review of the EPP occurred in 2023, and no updated version was available for the current year. This deficiency was identified during a survey on 6/9/25, where it was determined that the EPP had not been reviewed or updated within the required annual timeframe. The lack of an updated EPP could impact the facility's ability to ensure proper planning and preparation for the health and safety of all 90 residents, as the plan may not reflect current risks or procedures.
Plan Of Correction
The facility recognizes the importance of maintaining the emergency preparedness plan. The facility will continue to maintain the emergency preparedness plan every year by reviewing and updating the plan annually. The facility shall update the EPP on June 26, 2025, during the QA Committee meeting. The facility shall include the EPP review and update as part of the facility's annual review for all facility Policies and Procedures, to be conducted in January 2026 and then each consecutive year in the following January. The update will be communicated to staff during the all-staff meeting scheduled for June 26, 2025, coordinated by the Administrator and facility Environmental Services Supervisor. Further issues regarding the EPP annual update and approval will be received during the QA process and brought to the QAPI Committee for review. The Environmental Services Supervisor, Administrator, and QA Manager will be responsible to ensure ongoing compliance.
Failure to Annually Review and Update Emergency Operations Plan
Penalty
Summary
The facility failed to maintain compliance with federal regulations requiring the annual review and update of its Emergency Operations Plan (EOP). During a record review and interview with the Director of Subacute and the Director of Plant Operations, it was found that the EOP had last been reviewed and updated on 11/29/22. This was confirmed when the Director of Plant Operations stated that they believed the plan only needed to be reviewed every two years, following the hospital's review schedule, rather than annually as required for long-term care facilities. This deficiency affected all 59 patients in the facility, as the EOP had not been reviewed or updated within the required annual timeframe. The lack of timely review and update of the emergency preparedness plan could result in the facility being unprepared in the event of an emergency or disaster, as the plan may not reflect current procedures, resources, or risks.
Plan Of Correction
E 004 The director of plant operations revised the emergency operations plan. The emergency management committee approved the revised emergency operations plan and will be presented to the Subacute Quality Assurance and Performance Improvement committee for final approval. The Director of plant operations will be revising the emergency operations plan on an annual basis (within the first quarter of the year).
Failure to Annually Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan was reviewed and updated at least annually, as required by federal regulations for long-term care facilities. During a document review conducted on May 1, 2025, it was discovered that the plan had not been reviewed and updated within the required timeframe. This oversight affects the entire facility, as the emergency preparedness plan is a critical component of ensuring the safety and well-being of all residents and staff in the event of an emergency. An exit interview with the Maintenance Director on the same day confirmed the lack of documentation regarding the review and update of the Emergency Preparedness Plan. This indicates a lapse in the facility's compliance with federal emergency preparedness requirements, which mandate that such plans be maintained and updated annually to address potential hazards and ensure readiness for emergencies.
Plan Of Correction
Facility established and maintaining a comprehensive emergency preparedness program that meets the requirements. The Director of Maintenance or designee will audit to ensure Emergency Preparedness Plan policies and procedures are reviewed and updated at least annually, weekly x2, then monthly x2. All findings will be brought to QAPI for review.
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