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 that the facility failed to provide a written Emergency Preparedness (EP) Plan that includes a facility-based and community-based risk assessment.
Findings include:
1. Interview and documentation review of the EP plan on May 21, 2025, at 8:30 a.m., revealed the facility lacked an Emergency Preparedness Plan that includes an annually updated facility-based and community-based risk assessment, utilizing an all-hazards approach.
Interview with the Maintenance Supervisor on May 21, 2025, at 8:30 a.m., confirmed the above listed EP deficiency.
| | Plan of Correction - To be completed: 06/24/2025
The facility-based and community-based risk assessment, utilizing an all-hazards approach was previously completed on 1/2/2025 with a copy located in the Emergency Preparedness Manual. The Nursing Home Administrator and the Interdisciplinary Team, re-reviewed the facility-based and community-based risk assessment, utilizing an all-hazards approach. The Maintenance Director was educated on the Emergency Preparedness Manual, including the location of the facility-based and community-based risk assessment, utilizing an all-hazards approach. The Nursing Home Administrator will complete a random audit on the facility-based and community-based risk assessment, utilizing an all-hazards approach, to ensure annual and updated compliance. The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.
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