Deficiency in Emergency Preparedness Communication Plan
Summary
The facility failed to maintain and update an emergency preparedness communication plan that includes a method for sharing information from the emergency plan with residents and their families or representatives. During a document review on January 13, 2025, at 8:00 a.m., it was revealed that the emergency communications plan lacked this essential component, affecting the entire facility. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 10:30 a.m., where the lack of documentation was acknowledged.
Plan Of Correction
Facility established policy to share appropriate information from the facility's emergency plan with residents and their representatives. 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.
Penalty
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
The facility did not maintain an emergency preparedness communication plan that included a method for sharing information with residents and their families. A review and interview revealed the plan's deficiency, affecting the entire facility. The absence of documentation was confirmed by the Assistant Administrator and Maintenance Director.
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain and update an emergency preparedness communication plan that includes a method for sharing information from the emergency plan with residents and their families or representatives. During a document review and interview conducted on December 23, 2024, at 8:30 a.m., it was revealed that the emergency communications plan lacked a method for disseminating information to residents and their families or representatives. This deficiency affected the entire facility. An exit interview with the Assistant Administrator and the Maintenance Director confirmed the absence of the necessary documentation.
Plan Of Correction
Emergency preparedness plan has been reviewed and updated to include communication/notification to residents/representatives in an emergency situation. Maintenance Dir/designee will re-educate maintenance staff on timely updates for policies and procedures relating to communication/notification to residents/representatives in an emergency situation. NHA/designee will complete weekly audits x1 and monthly x2 to ensure EPP manual is updated. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.
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