Failure to Maintain and Update Emergency Preparedness Communication Plan
Summary
The facility failed to maintain and update its Emergency Preparedness Plan (EPP), specifically the Communication Plan component, as required by federal regulations. During a document review and staff interview, it was found that there were no records indicating the Communication Plan had been reviewed or updated at least annually. The last review date of the Communication Plan was unknown, and staff confirmed that the update had not yet occurred. This deficiency could affect all 92 residents in the facility, as the lack of an updated Communication Plan may delay the protection of their health and safety during an emergency. The findings were based on direct document review and staff interviews, with no evidence provided to show compliance with the annual review and update requirement for the Communication Plan.
Plan Of Correction
E 029: Development of Communication Plan 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 Communication Plan 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 Communication Plan to ensure all protocols for the protection of all residents during emergencies. An audit will be conducted on 4/10/25 to verify that the Communication Plan is 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 Communication Plan 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 Communication Plan by the new year. • The facility's emergency preparedness committee will convene quarterly to review the Communication Plan and make any necessary revisions. • The EVS Director was retrained on the importance of maintaining an updated Communication Plan, by the Administrator on 4/9/25.
Penalty
Surveyors identified that the facility did not maintain an annually updated emergency preparedness communication plan, as required by regulation. Staff confirmed the last review was in 2023, resulting in the absence of a current communication plan for all residents.
The facility's Emergency Preparedness (EP) Plan was found lacking a communication plan that complies with federal, state, and local laws. This deficiency was confirmed during interviews with the Facility Administrator and Maintenance Director, who acknowledged the absence of a compliant communication plan.
Failure to Annually Update Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain compliance with federal regulations requiring an annually reviewed and updated emergency preparedness communication plan. During a record review and interview with staff, surveyors found that the emergency preparedness plan (EPP) had not been updated since 11/15/23, and staff confirmed that the last review occurred in 2023. As a result, the facility did not have an up-to-date communication plan as required, affecting the planning and preparation for the health and safety of all 90 residents. No additional details regarding the medical history or condition of the residents at the time of the deficiency were provided in the report.
Plan Of Correction
The facility recognizes the importance of maintaining an updated communication plan. The facility shall continue to maintain an updated communication plan and review it annually. The facility shall update the emergency preparedness communication plan by June 26, 2025, during the QA Committee meeting. The communication plan shall be included when the facility reviews the emergency preparedness plan annually in January 2026 and each year consecutively in the following January. Further issues regarding the facility's development of a communication plan as part of the emergency preparedness plan 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 DON shall be responsible for monitoring and ongoing compliance.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness communication plan that complies with federal, state, and local laws. This deficiency was identified during a review of the facility's Emergency Preparedness (EP) Plan. On February 6, 2025, at 9:00 a.m., an interview and documentation review revealed that the EP Plan lacked a communication plan that met the required legal standards. This finding was confirmed during an interview with the Facility Administrator and Maintenance Director later that day at 1:00 p.m., who acknowledged the absence of a compliant communication plan in the EP Plan.
Plan Of Correction
Facility emergency preparedness plan will be updated to include communication plan that complies with local, state and federal laws by 3/21/2025. A review of policies and procedures will be conducted on an annual basis by the Administrator or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.
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