Deficiency in Emergency Preparedness Program
Summary
The facility failed to incorporate the use of volunteers and other emergency staffing strategies in their Emergency Preparedness Program (EP) as required by the Code of Federal Regulations (CFR). During a record review conducted on April 30, 2025, it was found that the facility's EP lacked policies and procedures detailing the process and role for integrating State and Federally designated health care professionals to address surge needs during an emergency. This deficiency was identified during a review of the facility's documentation with the Administrator. An interview with the Administrator, conducted concurrently with the record review, confirmed the absence of these critical policies and procedures. The Administrator acknowledged the findings, which were subsequently reviewed with both the Administrator and the Director of Plant Operations during the exit conference on the same day. The lack of a comprehensive plan for utilizing volunteers and integrating designated health care professionals during emergencies represents a significant gap in the facility's emergency preparedness efforts.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The Executive Director was educated by the Regional Director of Operations on 05/16/2025 regarding E024. The policy for E024 was updated by the Executive Director on 05/16/2025 to reflect the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. The policy was approved by the QAPI committee on 05/21/2025. The policy will be maintained in the Executive Director's office and reviewed annually or as needed.
Penalty
Surveyors found that the facility did not have a policy or procedure in its Emergency Preparedness plan explaining the use of volunteers or other emergency staffing strategies, as required. During document review and interviews, the Administrator was unaware of the missing policy, and the facility did not provide the required documentation when given the opportunity. This deficiency affected all residents.
The facility's emergency preparedness plan was found deficient due to missing policies and procedures for using volunteers and integrating State and Federally designated health care professionals during emergencies. This deficiency, affecting the entire facility, was confirmed during a document review and exit interview with the Administrator and Maintenance Director.
Missing Emergency Staffing and Volunteer Policy in EP Plan
Penalty
Summary
The facility failed to maintain its Emergency Preparedness (EP) plan by not providing a policy and procedure that explains the use of volunteers or other emergency staffing strategies. During a document review and interview with the Maintenance Director and Administrator, surveyors requested the EP policies and procedures and found that there was no documentation addressing the facility's use of volunteers or integration of state and federally designated health care professionals to address surge needs during an emergency. The Administrator, who had recently started working at the facility, was unaware of the missing policy. This deficiency affected all 120 residents in the facility, as the lack of a documented policy could result in an ineffective emergency preparedness plan. The facility was given an opportunity to submit the missing records, but no records were received by the specified deadline.
Plan Of Correction
E024 - Policies/Procedures: Volunteers and Staffing 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/12/25, the facility developed a written policy outlining procedures for the use of volunteers and alternative staffing during emergencies. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected during emergency staffing shortages or volunteer involvement. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/2025, the policy was incorporated into the facility's Emergency Preparedness Plan. All department heads were trained on how to implement the policy during an emergency. 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 review of the Emergency Preparedness Plan. 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. E 024
Deficiency in Emergency Preparedness Plan
Penalty
Summary
The facility was found deficient in its emergency preparedness plan due to the absence of policies and procedures addressing the use of volunteers and other emergency staffing strategies during an emergency. Specifically, the plan lacked documentation on the process and role for integrating State and Federally designated health care professionals to address surge needs during an emergency. This deficiency was identified during a document review conducted on January 13, 2025, at 8:00 a.m. During an exit interview with the Administrator and the Maintenance Director later that morning, the lack of documentation was confirmed. The deficiency affects the entire facility, as the emergency preparedness plan is a critical component in ensuring adequate staffing and resource allocation during emergencies. The absence of these policies and procedures indicates a gap in the facility's ability to effectively manage and respond to emergency situations.
Plan Of Correction
Facility established policy for the use of volunteers in an emergency or other staffing strategies. 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.
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