Pandemic Emergency Plan Not Publicly Available
Summary
The facility failed to comply with New York State Public Health Law 2803-12 by not making its Pandemic Emergency Plan (PEP) available to the public on its website. According to the New York State Department of Health Dear Administrator Letter Nursing Home 20-09, each residential health care facility was required to prepare and make the PEP available to the public on the facility's website by a specified date in 2020. During an interview on December 5, 2024, the Administrator confirmed that while the facility had a PEP, it was not accessible to the public on the website. A review of the facility's website with the Administrator corroborated that the PEP was indeed missing from the site.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 1. Facility posted Pandemic Emergency Plan on website. 2. All residents are at risk for not having accessibility of the PEP plan available to them per policy and procedure for PEP. 3. PEP was reviewed by Administrator and changes were made to PEP prior to posting to website. 4. Admissions staff will be educated on process of posting up to date PEP by Administrator. 5. The QAPI reviewed PEP prior to posting to website. The PEP will be brought to QAPI quarterly and website will be checked quarterly by Administrator to ensure compliance. Person Responsible: Administrator
Penalty
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