|(2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following:|
*[For LTC Facilities at §483.73(d):] (2) Testing. The LTC facility must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The LTC facility must do all of the following:]
(i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based.
(B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For RNHCIs at §403.748 and OPOs at §486.360] (d)(2) Testing. The [RNHCI and OPO] must conduct exercises to test the emergency plan. The [RNHCI and OPO] must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the [RNHCI's and OPO's] response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
Name: - Component: -- - Tag: 0039
Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to maintain documentation of exercises to test the emergency plan.
1. Interview and documentation review on February 7, 2019, at 9:35 a.m., revealed the facility lacked documentation of exercises conducted to test the emergency plan at least annually.
Interview with the Facility Administrator and Maintenance Director on February 7, 2019, at 9:35 a.m., confirmed the documentation of exercises was not maintained.
| ||Plan of Correction - To be completed: 03/04/2019|
A full scale community based emergency fire drill was conducted on Feb 19,20019 at 2:30 pm. Facility census was 15 and all 15 residents were evacuated to the community next door. All emergency resident information and e-mars were transported and evacuated with the residents. A head count revealed the evacuation was complete in 5 minutes. Mr. Tom Bonura, Fire Instructor/Inspector was present to supervise the disaster drill. All staff were in-serviced by the DON and Maintenance Manager on disaster Training on Feb 19-20, 2019. Disaster codes were placed on the back of all staff name tags and disaster codes were posted in the nurses station, the physical therapy gym, Maintenance , Dietary and Housekeeping offices and employee lounge. To ensure the deficiency does not reoccur a full scale tornado disaster has been planned for August of 2019. This will be coordinated with the local EMS Department. Disaster Training Education will be provided to all new employees at the time of hire and before unsupervised job duties. This will be conducted for all employees upon hire and annually by the Executive Director and the Maintenance Manager. The education will be part of the employee personnel record. The Business Office Manager or designee will audit employee personnel records monthly x4 for compliance. Disaster drills and Disaster Education will be reported to the QAPI Committee for the next 3 quarters. Any non-compliance issues will be reviewed and corrected.