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 the facility failed to provide documentation verifying the emergency preparedness plan had been reviewed within the previous twelve months, affecting the entire component.
Findings include:
1. Review of documentation on January 8, 2024, at 9:00 AM, revealed the facility failed to provide documentation verifying the emergency preparedness plan had been reviewed since April 12, 2018.
Interview with the Director of Facilities on January 8, 2024, at 9:00 AM, confirmed the lack of documentation verifying the emergency preparedness plan had been reviewed within the previous twelve months.
| | Plan of Correction - To be completed: 03/15/2024
1. QAPI Committee will systematically review the Emergency Preparedness Plan and make necessary revisions and updates to ensure optimal safety protocol is in place for the protection of residents and staff.
2. This review will be completed on or before February 28th, 2024.
3. QAPI will add Emergency Plan to annual review of operational and dietary policies and procedures to ensure this does not recur. This review should begin in the fourth quarter annually to be completed in January.
4. An audit is not appropriate for this plan of correction
5. QAPI will review as needed and annually.
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