403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually: | |
§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).
The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:
(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:
* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.
* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.
* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.
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Observations: Name: - Component: -- - Tag: 0004
Based on document review and interview it was determined that the facility failed to develop and maintain an Emergency Preparedness Plan that must be reviewed and updated at least annually, for one of one plan.
Findings include:
Document review on January 29, 2024, at 10:00 a.m., revealed the facility failed to update local resources, and key personnel on its succession plan during the annual review of the Emergency Preparedness Plan.
Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 p.m., confirmed the incomplete annual update.
| | Plan of Correction - To be completed: 03/15/2024
1. The facility updated the local resources, and key personnel of the Emergency Preparedness Plan. 2. The Maintenace Director/Designee will complete routine audits to ensure the Emergency Preparedness Plan is updated with current information. 3. Maintenance Director/Designee will educate the staff on the requirements of ensuring that the Emergency Preparedness Plan is updated and current. 4. The Maintenance Director/Designee will complete monthly audits x 3 months to ensure the local resources, and key personnel of the Emergency Preparedness Plan is updated and will be reviewed for the QAPI committee.
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