| 403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment: |  |
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)
[(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 the following:]
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*
(2) Include strategies for addressing emergency events identified by the risk assessment.
* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
*[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. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.
*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
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Observations:
Name: - Component: -- - Tag: 0006
Based on document review and interview, it was determined the facility failed to develop an emergency preparedness plan that included a facility and community risk assessment.
Findings include:
1. Documentation review on December 8, 2025, at 8:40 a.m., revealed that a facility and community risk assessment using an all-hazards approach was not updated in the emergency preparedness plan within the last twelve months.
Interview with the Facility Administrator and Maintenance Director on December 8, 2025, at 1:30 p.m., confirmed a risk assessment was not updated for the emergency preparedness plan within the last twelve months.
| | Plan of Correction - To be completed: 01/02/2026
1. Emergency Preparedness manual plan has been developed by facility, which includes updated policy/ procedures, facility-based and community-based risk assessment, utilizing an all-hazards approach. This includes identifying emergency events by conducting risk assessments, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care to assure compliance.
2. Maintenance director or designee will educate staff members on the Emergency Preparedness Plan, newly updated policy/procedures, along with manual location.
3. The new updated policy/procedures manual will be reviewed at the January 2026 (QAPI) quality assurance performance improvement meeting. Yearly and bi-yearly reviews and as policies are updated of emergency preparedness manual will be conducted to include any/all revised policies /procedures and which will include date month and year noted at such time as completed to assure compliance.
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