Failure to Maintain and Update Emergency Preparedness Policies and Procedures
Summary
The facility failed to maintain and update its Emergency Preparedness Plan (EPP) as required. During a document review and staff interview, it was found that there were no documents available to show that the Emergency Preparedness (EP) policies and procedures had been reviewed or updated at least annually. The date of the last review was unknown, and staff confirmed that the EPP policies and procedures had not yet been updated. This deficiency affected all 92 residents in the facility, as the lack of updated EP policies and procedures could result in a delay in protecting their health and safety during emergencies. The findings were based on direct document review and staff interviews conducted during the survey.
Plan Of Correction
The EVS Director or designee will conduct quarterly audits of the EPP to ensure it remains updated. The results of these audits will be reported during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. Any deficiencies identified during audits will be addressed immediately, and corrective actions will be documented. **Date of Compliance: 4/18/25** **E 013: Development of EP Policies and Procedures** How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The facility initiated a review and update of the Emergency Preparedness (EP) Policies and Procedures upon identification of the deficiency. The facility's leadership and emergency preparedness team have reviewed the updated plan on 4/9/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected. The facility will update the Emergency Preparedness (EP) Policies and Procedures to ensure all protocols for the protection of all residents during emergencies. An audit will be conducted on 4/10/25 to verify that all Emergency Preparedness (EP) Policies and Procedures are up to date. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: The facility has established a process to review and update the Emergency Preparedness (EP) Policies and Procedures annually. The policy now requires the administrator or designee to document the annual review in a designated log. A calendar reminder has been set for December 1st of each year to ensure timely review and update of the Emergency Preparedness (EP) Policies and Procedures by the new year. The facility's emergency preparedness committee will convene quarterly to review emergency protocols and make any necessary revisions. The EVS Director was retrained on the importance of maintaining an updated Emergency Preparedness (EP) Policies and Procedures by the Administrator on 4/9/25. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The EVS Director or designee will conduct quarterly audits of the Emergency Preparedness (EP) Policies and Procedures to ensure it remains updated. The results of these audits will be reported during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. Any deficiencies identified during audits will be addressed immediately, and corrective actions will be documented.
Penalty
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
The facility did not ensure that emergency preparedness policies and procedures matched actual resources and practices. Staff were directed to use an emergency kit cart in a location where it was not present, and the severe weather policy referenced a weather radio at the main nurse station that did not exist. These discrepancies were confirmed during record review and interview with the maintenance director.
Surveyors identified that the facility did not update its emergency preparedness plan (EPP) policies and procedures within the required annual timeframe. Staff confirmed the last review was in 2023, resulting in a deficiency for not maintaining current EPP documentation for all residents.
The facility did not update its emergency preparedness policy after upgrading its backup generator, leaving staff with outdated instructions to use extension cords and red outlets for backup power, which no longer reflected the facility's current emergency power capabilities.
Surveyors identified that the facility did not have emergency preparedness policies and procedures in place for the loss of natural gas, as required. This deficiency was confirmed by the Maintenance Director during record review, indicating the facility failed to address how operations would be maintained if natural gas service was interrupted.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Deficient Emergency Preparedness Policies and Procedures
Penalty
Summary
The facility failed to develop and implement emergency preparedness policies and procedures in accordance with regulatory requirements. Specifically, the emergency plan, risk assessment, and communication plan were not fully integrated into the facility's policies and procedures, and the required annual review and update of these documents was not completed. During record review, it was found that the policy for emergency situations involving electrical power outages directed staff to use an 'emergency kit' cart located in the 500 Hall. However, field verification revealed that there was no emergency kit cart in the 500 wing, as it had been moved to the 600 service hall without updating the policy or informing staff of the new location. Additionally, the facility's severe weather policy stated that staff would monitor a weather radio located at the main nurse station. Upon field verification, it was discovered that there was no weather radio at the main nurse station, contrary to what the policy indicated. These discrepancies were confirmed through an interview with the maintenance director at the time of record review. The lack of alignment between the facility's written policies and the actual resources and equipment available could affect all occupants in the event of an emergency.
Failure to Annually Update Emergency Preparedness Plan Policies and Procedures
Penalty
Summary
The facility failed to maintain and update its emergency preparedness plan (EPP) policies and procedures as required. During a record review and interview with staff, it was found that the EPP had not been updated annually, with the last documented review occurring in November 2023. Staff confirmed that the most recent review date was in 2023, indicating that the required annual update had not been completed. This deficiency was identified during a survey in which the EPP was specifically requested and examined. The lack of an updated EPP could result in the absence of proper planning and preparation to protect the health and safety of all 90 residents in the facility. No additional details about individual residents or their medical conditions were provided in the report.
Plan Of Correction
The facility recognizes the importance of maintaining the emergency preparedness plan (EPP). The facility shall continue to ensure the emergency preparedness plan has updated policies and procedures. The facility shall update the emergency preparedness plan policies and procedures by June 26, 2025, during the QA Committee meeting. The facility shall include the reviewed and updated emergency preparedness plan policies and procedures as part of the annual review for all facility policies and procedures to be conducted in January 2026, and then each consecutive year in the following January. Further issues regarding the facility's emergency preparedness plan's policies and procedures shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, and Director of Nursing shall be responsible to ensure ongoing compliance. This page is purposefully left blank.
Failure to Update Emergency Power Loss Policy After Generator Upgrade
Penalty
Summary
The facility failed to update its Emergency Preparedness policies and procedures following an upgrade to the emergency backup generator. Although the generator was enhanced to cover the power load of the entire facility, the written policy still instructed staff to use extension cords and red outlets to provide backup power only to certain resident rooms and treatment areas. This outdated information did not reflect the current capabilities of the upgraded generator. During a record review and interview with the maintenance director, it was confirmed that the utility power loss policy had not been revised to align with the new generator system. The continued reference to outdated procedures in the policy could cause confusion among staff during a power outage emergency, as the instructions no longer matched the facility's actual emergency power resources.
Deficient Emergency Preparedness Policy for Natural Gas Interruption
Penalty
Summary
The facility failed to develop and implement emergency preparedness policies and procedures specifically addressing the loss of natural gas to the building. During a record review, it was found that there were no established policies outlining how the facility would maintain operations in the event of an interruption to the natural gas supply. This omission was identified as a deficiency in the facility's emergency preparedness planning. The deficiency was confirmed during an interview with the Maintenance Director at the time of the record review. The lack of a policy for natural gas interruption means the facility did not meet the requirement to review and update emergency preparedness policies and procedures at least annually, as mandated. This finding could potentially affect all occupants in the event of an emergency involving the loss of natural gas.
Plan Of Correction
Element 1: Policy for Natural Gas Outage created on 06/04/2025. Element 2: All residents have the potential to be impacted by this deficiency. Best practice is to have a policy surrounding natural gas outage. Element 3: Physical plant manager and Administrator created policy and staff were educated on 06/05/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance.
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