Deficiency in Emergency Preparedness Planning
Summary
The facility was found deficient in its emergency preparedness planning, specifically in failing to develop and document policies and procedures concerning its role under a waiver declared by the Secretary of the Department of Health, in accordance with section 1135 of the Act. This deficiency was identified during a document review conducted on December 18, 2024, which revealed that the facility did not have an Emergency Preparedness Plan that included the necessary provisions for care and treatment at an alternate care site as identified by emergency management officials. During the exit interview with the Administrator, Administrator in training, and Maintenance Director, it was confirmed that the facility lacked the required documentation. This deficiency affects the entire facility, as it does not have the necessary policies and procedures in place to guide its actions under a waiver declared by the Secretary, potentially impacting its ability to provide care and treatment at alternate care sites during emergencies.
Plan Of Correction
Paperwork has been downloaded regarding the waiver of the Secretary of State regarding section 1135 of the Act. This will be implemented and added to our Emergency Preparedness plan by January 1st, 2025.
Penalty
Surveyors found that the facility’s Emergency Preparedness (EP) Plan did not include required written procedures describing the facility’s role under a Section 1135 waiver declared by the Secretary of Health and Human Services. During document review and staff interviews, the EP Plan was confirmed to lack policies addressing how the facility would provide care and treatment at an alternate care site designated by emergency management officials when such a waiver is in effect.
Surveyors found that the facility's Emergency Preparedness Plan did not include required procedures outlining the facility's role under a waiver declared by the Secretary of the Department of Health, specifically regarding care provision at an alternate care site as identified by emergency management officials. This omission was confirmed by facility leadership during interviews.
Surveyors found that the facility did not have required policies and procedures for providing care at an alternate care site under an 1135 waiver. During review and interviews, the Administrator was unaware of the missing policy, and the facility could not provide the necessary documentation for all residents when requested.
Wyndmoor Hills Rehabilitation And Nursing Center was found deficient in their Emergency Preparedness plan, as it lacked policies and procedures for providing care at alternate sites during emergencies under an 1135 waiver. This deficiency was confirmed during a survey and an exit interview with the facility's Administrator and Maintenance Director.
The facility's emergency preparedness plan lacked documentation on the role of the Ambulatory Surgical Center under a waiver declared by the Secretary, affecting the entire facility. This was confirmed during a document review and an exit interview with the Administrator and Maintenance Director.
The facility failed to provide documentation on its role under a waiver declared by the Secretary, as required by section 1135 of the Act. This deficiency was confirmed during a document review and an exit interview with the Administrator and Maintenance Director, affecting the entire facility's emergency preparedness.
Failure to Include 1135 Waiver Role in Emergency Preparedness Plan
Penalty
Summary
The deficiency involves the facility’s failure to include required procedures in its Emergency Preparedness (EP) Plan addressing the facility’s role under a waiver declared by the Secretary of the Department of Health and Human Services in accordance with Section 1135 of the Social Security Act. During a review of the EP Plan, surveyors determined that it did not contain policies or procedures describing how the facility would provide care and treatment at an alternate care site identified by emergency management officials when such a federal waiver is in effect. On the survey date and time, an interview and documentation review confirmed that there were no written procedures in the EP Plan outlining the facility’s responsibilities or actions under an 1135 waiver scenario. In a subsequent interview, the Facility Administrator and Maintenance Director acknowledged that the EP Plan lacked a written plan describing the facility’s role during a waiver declared by the Secretary of the Department of Health.
Plan Of Correction
The facility added the information related to 1135 waiver under the Stafford Act or National Emergency Act to out disaster plan in the event that the President declares a disaster or emergency. Also the HHS Secretary declares a public health emergency under Section 319 of the Public Health Service Act. The department heads will be in serviced on this added information by the Maintenance director / designee. The review of this information as well as the entire disaster manual will be reviewed yearly by the maintenance director and Nursing Home Administrator to ensure that the policy and procedures remain pertinent to regulations. The review of emergency policy and procedures will be discussed in Quality Assurance and Performance Improvement committee meetings monthly for two months then annually.
Missing Emergency Preparedness Procedures for 1135 Waiver
Penalty
Summary
The facility failed to include procedures in its Emergency Preparedness (EP) Plan that address the role of the facility under a waiver declared by the Secretary of the Department of Health, as required by Section 1135 of the Act. During a review of the EP Plan and interviews conducted, it was found that the plan did not contain written procedures for the provision of care at an alternative care site identified by emergency management officials during such a waiver. This deficiency was confirmed through both documentation review and interviews with the Facility Administrator and Maintenance Director, who acknowledged that the EP plan lacked the necessary written plan outlining the facility's responsibilities and actions during a waiver situation. No information about specific residents or their medical conditions was included in the findings.
Plan Of Correction
A plan for the role of the facility under a waiver declared by the Secretary of the Department is now present in the facility. The Maintenance Director/designee will ensure procedures to address the role of the facility under a waiver declared by the Secretary, in accordance with Section 1135 of the Act, in the provision of care at an alternative care site identified by emergency management officials is included in the Emergency Preparedness Plan. The Facility Administrator will ensure compliance by confirming the Emergency Preparedness Plan contains a written plan of the facility's role during a waiver declared by the Secretary of the Department of Health monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings.
Missing Emergency Preparedness Policy for 1135 Waiver Alternate Care Site
Penalty
Summary
The facility failed to develop and implement policies and procedures outlining its role in providing care and treatment at an alternate care site under an 1135 waiver, as required by federal regulations. During a document review and interview with the Maintenance Director and Administrator, surveyors requested the Emergency Preparedness policies and procedures. The facility was unable to provide documentation indicating a plan for the provision of care at an alternate location in the event of an emergency requiring activation of an 1135 waiver. The Administrator, who was new to the facility, stated she was not aware that the required policy was missing. The absence of this policy 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 survey agency.
Plan Of Correction
E 026 E026 - Roles Under a Waiver Declared by the Secretary 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/12/2025, the Emergency Preparedness Plan was updated to include a policy addressing alternate care sites and adjusted staffing/licensure protocols. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected in the event of a federally declared emergency requiring relocation or altered care settings. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: The facility incorporated all guidelines into the Emergency Plan and added procedures for continuity of care in alternate locations on (date). 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 inspection of the Emergency Plan to ensure waiver protocols are included and current. 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.
Deficiency in Emergency Preparedness Plan at Wyndmoor Hills
Penalty
Summary
Wyndmoor Hills Rehabilitation And Nursing Center was found to have a deficiency related to their Emergency Preparedness (EP) plan during a survey conducted on January 27, 2025. The facility failed to develop and implement policies and procedures that included their role in providing care and treatment at alternate care sites during emergencies, as required under an 1135 waiver declared by the Secretary. This deficiency was identified through a document review and confirmed during an exit interview with the Administrator and Maintenance Director. The survey revealed that the facility's EP plan did not address the facility's responsibilities in the event of an emergency that necessitates care at alternate sites, as identified by emergency management officials. This oversight affects the entire facility, as the EP plan is a critical component in ensuring preparedness and response during emergencies. The absence of these policies and procedures was confirmed during the exit interview, highlighting a gap in the facility's emergency preparedness strategy.
Plan Of Correction
1. Emergency preparedness plan was immediately updated with policy and procedures for 1135 waiver. 2. Emergency preparedness plan was audited to ensure proper compliance. 3. Education provided to ensure proper compliance with this regulation. 4. Emergency preparedness plan will be audited to ensure proper compliance 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Deficiency in Emergency Preparedness Plan Documentation
Penalty
Summary
The facility was found to be deficient in its emergency preparedness plan, specifically lacking policy and procedure documentation regarding the role of the Ambulatory Surgical Center under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficiency affects the entire facility as it pertains to the provision of care and treatment at an alternate care site identified by emergency management officials. During a document review on January 21, 2025, it was revealed that the facility could not provide the necessary documentation for their Emergency Preparedness Plan concerning the roles under a waiver declared by the Secretary. An exit interview with the Administrator and the Maintenance Director confirmed the absence of this critical documentation.
Plan Of Correction
The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulation, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. The Emergency Prepared Plan policy and procedure documentation concerning the Roles under a Waiver Declared by Secretary was located and placed in the Emergency Prepared Plan. The Maintenance Director was in-serviced on ensuring that the Emergency Prepared Plan is complete and updated. The Maintenance Director will monitor and review this plan of correction at the monthly Quality Assurance Performance Improvement meeting to ensure compliance is maintained.
Lack of Emergency Preparedness Documentation Under Waiver
Penalty
Summary
The facility failed to provide the necessary policy and procedure documentation regarding its role under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficiency was identified during a document review conducted on January 13, 2025, at 8:00 a.m. The review revealed that the facility did not have an Emergency Preparedness Plan that included the required documentation concerning the roles under a waiver declared by the Secretary. An exit interview with the Administrator and the Maintenance Director confirmed the absence of this critical documentation. The lack of documentation affects the entire facility, as it pertains to the provision of care and treatment at an alternate care site identified by emergency management officials. This deficiency highlights a significant gap in the facility's emergency preparedness policies and procedures.
Plan Of Correction
Facility established policy to establish roles for providing care during emergencies under blanket or specific $1135 waivers. 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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
