Failure to Participate in Required Emergency Preparedness Exercise
Summary
The facility failed to comply with emergency preparedness requirements as outlined in Appendix Z of the State Operations Manual. Specifically, the facility did not participate in a full-scale community-based emergency preparedness exercise in 2023, affecting all five resident units. The facility's Emergency Preparedness Manual, reviewed by the Administrator and Assistant Administrator in 2024, stated that the facility would conduct two separate exercises annually, including a community-based full-scale exercise. However, there was no evidence of participation in such an exercise in 2023. Interviews with the Assistant Administrator and Administrator revealed that the facility was a member of the Western New York Mutual Aid Plan but did not participate in any community-wide drills offered in 2023. The Administrator indicated that the responsibility for arranging participation in these drills fell to the Director of Maintenance, who missed the exercise in 2023. Although the Administrator believed there was a loss of power drill involving community partners in 2023, no documentation could be found to support this. Additionally, the Administrator mentioned that the facility likely activated their Emergency Preparedness Plan during a regional blizzard in 2022, but could not recall any activation in 2023. The lack of documentation and participation in required exercises led to the deficiency under 42 CFR 483.73-Emergency Preparedness.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 Corrective action for the deficient practice is to conduct two community-based disaster drills on an annual basis understanding only one is necessary. As participants in the Western New York Mutual Aid plan, the facility is due again in (MONTH) 2025 for an annual drill and will participate in two community-wide drills prior to 10/2025. The Director of Maintenance, Nursing Educator, and Administrator will keep these events in a logbook. The task will also be scheduled in the TELS maintenance program. The Director of Facilities Maintenance for ElderWood LLC will educate the Administrator as well as the Director of Maintenance and Nursing Educator on the requirements for two community-based disaster drills. The schedule and plan for facility inclusion in the two drills will be brought to the QA meeting on a monthly basis, and compliance will be documented at the time of both events. In the event the facility is unable to participate in either of these scheduled events, the facility will determine within 30 days a new date for the missed event to meet this requirement. Policy will be reviewed in Monthly QA for 3 months. Responsible Designee - Maintenance Director
Penalty
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