Failure to Establish and Maintain Emergency Subsistence Policies and Procedures
Summary
The facility failed to develop and implement adequate policies and procedures to ensure the provision of subsistence needs for staff and patients during emergencies, as required by federal regulations. During an interview, the Dietary Manager was unable to confirm the existence of a three-day emergency menu and stated that food provisions would be based on the regular menu cycle. The Dietary Manager also expressed uncertainty about how the facility would manage food service if dietary staff were unable to work due to weather conditions. It was noted that a three-day emergency menu had previously existed but was not re-established after a change in food vendors. Additionally, a review of the facility's emergency preparedness plan revealed inconsistencies regarding water supply arrangements. The written policy indicated reliance on one vendor for emergency water provision, while the Administrator reported having a contract with a different vendor not reflected in the plan. These deficiencies indicate a lack of clear, updated, and actionable procedures to ensure the availability of food, water, and other essential resources for staff and patients in the event of an emergency.
Penalty
The facility did not have documented agreements with a water supplier for emergency drinking water and relied on an onsite well that had not been observed to function by maintenance staff, resulting in a failure to ensure subsistence needs for staff and patients during emergencies.
The facility was found deficient in its Emergency Preparedness Program for failing to include procedures for sewage and waste disposal for all 56 residents. This was identified during a record review with the Maintenance Director and Regional Maintenance Consultant, who acknowledged the absence of such procedures. The issue was discussed with the facility's administration during an exit conference.
Surveyors found that the facility did not maintain enough safe emergency food to meet the needs of its emergency menu. During inspection, the emergency food shelf contained mostly canned vegetables and lacked required entrée items such as Beef Stew, Chili with Beans, Chicken and Dumplings, and Corn Beef Hash, which were listed on the emergency menu but not present onsite. The Certified Dietary Manager stated that some emergency food had been used for regular meals and that the facility was transitioning between menus.
Deficient Emergency Preparedness for Subsistence Needs
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure the provision of subsistence needs for staff and patients during an emergency, as required by federal regulations. Specifically, the emergency preparedness plan did not include documentation of an established relationship or emergency contract with a water supplier to provide drinking water in the event of an emergency. Although the plan referenced the intention to secure such an agreement, no evidence was provided to confirm that this had been accomplished by the time of the survey exit. Additionally, the facility's emergency plan cited the use of an onsite well as an alternative water source during emergencies. However, interviews with the Maintenance Director and his assistant revealed that neither had observed the well functioning during their respective tenures of approximately three and sixteen years. This lack of operational verification further demonstrated the facility's failure to ensure reliable access to water for subsistence needs in emergency situations.
Plan Of Correction
1. The facility failed to establish relations and obtain an agreement with a water supplier to provide the facility water in the event of an emergency. 2. Failure to ensure the facility has an agreement with a drinking water supplier could affect all residents, employees, and visitors in the event of an emergency. 3. The maintenance director has obtained an emergency drinking water agreement with Norway Springs to provide the facility with drinking water in the event of an emergency. The maintenance director has been educated on the importance of maintaining drinking water sources/agreements. 4. The Administrator is responsible for ensuring drinking water agreements are established and implemented at the facility and report to the QA committee. 5. The facility failed to maintain an accurate policy for emergency water within the emergency preparedness plan, specifically pertaining to the use of an existing onsite water well resource. 6. Failure to ensure all water emergency water sources are in place and accurate could affect all residents, employees, and visitors in the event of an emergency. 7. The onsite water well is currently not in use and has been removed from the facility emergency preparedness plan. The maintenance director has been educated on the importance of maintaining accurate emergency water resources and policies within the facility. 8. The Administrator is responsible for the implementation of accurate policies and procedures pertaining to emergency water in the event of an emergency and report to the QA committee.
Deficiency in Emergency Preparedness: Lack of Sewage and Waste Disposal Procedure
Penalty
Summary
The facility failed to incorporate procedures for sewage and waste disposal into their Emergency Preparedness Program (EPP) for all 56 residents. This deficiency was identified during a record review conducted with the Maintenance Director and the Regional Maintenance Consultant. The review took place on March 31, 2025, between 9:30 a.m. and 1:30 p.m. During this review, it was found that the facility did not have a procedure in place for sewage and waste disposal in the event of a system loss. An interview with the Maintenance Director and the Regional Maintenance Consultant confirmed the absence of this procedure. These findings were subsequently discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during an exit conference held on the same day between 4:15 p.m. and 4:30 p.m. The lack of a sewage and waste disposal procedure is a violation of the Code of Federal Regulations, specifically 42 CFR § 483.73(b)(1)(D).
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The QA & A committee will review to approve the procedure for sewage and waste disposal on 4/24/2025. 2. No other areas or residents were affected by deficient practice. 3. Education provided to the Maintenance Director by NHA or designee on procedures for sewage and waste disposal by 4/24/2025. 4. All policies and procedures will be reviewed and monitored annually by the QA & A committee.
Insufficient Emergency Food Supplies for Emergency Menu
Penalty
Summary
The facility failed to provide sufficient safe emergency food to meet the requirements of its emergency menu. During a tour of the dry storage room, it was observed that the shelf labeled 'Emergency Food' contained minimal entrée items and mostly canned vegetables, which are typically used to accompany entrée meals. An interview with the Certified Dietary Manager revealed that some of the emergency food had been used to supplement regular menu items before expiration, and the facility was in the process of transitioning between different menus with the assistance of a culinary vendor. A review of the emergency menu showed that items such as Beef Stew, Chili with Beans, Chicken and Dumplings, and Corn Beef Hash were listed, but none of these entrée items were found onsite during the evaluation. This lack of required emergency food provisions was identified through observation, interview, and record review, indicating a failure to maintain adequate subsistence supplies as mandated by emergency preparedness regulations.
Plan Of Correction
E015 1. No residents were harmed as a result of this deficient practice. 2. An emergency food supply was purchased and in the facility by 4/30/2025. 3. The CDM was educated by the NHA by 4/25/2025 on the Emergency Food Supply Policy and Procedure. An emergency food agreement was obtained by the food. 4. The QAPI Committee has directed the CDM/Designee to perform random weekly audits of emergency food supply in the facility. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
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