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Based on documentation and staff interview, the facility failed to comply with Emergency Preparedness Plan (EPP), develop and maintain an EP Plan. The Plan must be reviewed and updated annually. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The finding included:

During documentation review and staff interview on 08/07/19 at 1:15 PM with the Administrator, it was revealed that the facility's Emergency Preparedness Plan failed to include all essential elements, including but not limited to, review and updated annually. The Administrator acknowledged the absence of the complete Emergency Preparedness Plan that includes an annual review and update of the EPP.
The new Administration stated that sections of the EPP (Emergency Preparedness Plan) were missing and could not be located due to change in staff.

Based on documentation and staff interview, the facility failed to comply with Emergency Preparedness Plan, develop and maintain policies and procedures. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The finding included:

During documentation review and staff interview on 08/07/19 at 3:30 PM with the Administrator, it was revealed that the facility's Emergency Preparedness Plan failed to include all essential elements, including but not limited to, a complete plan with policies and procedures. The Administrator acknowledged the absence of the complete Emergency Preparedness Plan.
The new Administration stated that sections of the EPP (Emergency Preparedness Plan) were missing and could not be located due to change in staff.

Based on documentation and staff interview, the facility failed to comply with Emergency Preparedness Plan, develop and maintain policies and procedures for medical documents. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The finding included:

During documentation review and staff interview on 08/07/19 at 2:10 PM with the Administrator, it was revealed that the facility's Emergency Preparedness Plan failed to include all essential elements, including but not limited to, a system of medical documentation that preserves patient information, protect confidentially and patient information, and secures and maintain availability of records. The Administrator acknowledged the absence of the complete Emergency Preparedness Plan.
The new Administration stated that sections of the EPP (Emergency Preparedness Plan) were missing and could not be located due to change in staff.

Based on written document review and staff interview, the facility failed to include all of the requirements that CMS Centers for Medicare & Medicaid Services require for the facility emergency plan and policies to meet code requirements. This deficient practice affects all staff, visitors and all residents.

The findings included:

On 08/07/19 at 12:30 PM, based on conversation with the Administrator, there is no written documentation for the required facility federal emergency plan and policy to meet code requirements, and the facility was not able to produce requested written documentation, policies and procedures for the use of volunteers, including the process and role for intergration of State & Federally designed healthcare professionals to address the surge needs during an emergency. An interview was conducted at this time with the administrator who acknowledged that the documentation requested was not available in a written facility federal emergency plan.
The new Administration stated that sections of the EPP (Emergency Preparedness Plan) were missing and could not be located due to change in staff.

Based on written document review and staff interview, the facility failed to include all of the requirements that CMS Centers for Medicare & Medicaid Services require for the facility emergency plan and policies to meet code requirements. This deficient practice affects all staff, visitors and all residents.

The findings included:

On 08/07/19 at 1:15 PM, based on conversation with the Administrator, there is no written documentation for the required facility federal emergency plan and policy to meet code requirements, the facility was not able to produce requested written documentation,the role of the facility under the waiver declared by the secretary in accordance with section 1135 of the Act. An interview was conducted at this time with the Administrator who acknowledged that the documentation requested was not available in a written facility federal emergency plan.
The new Administration stated that sections of the EPP (Emergency Preparedness Plan) were missing and could not be located due to change in staff. No additional documentation was provided at the time of exit.

The findings were acknowledged by and verified by the Administrator.

Based on documentation and staff interview, the facility failed to comply with Emergency Preparedness Plan, develop and maintain comprehensive communication plan. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The finding included:

During documentation review and staff interview on 08/07/19 at 4:15 PM with the Administrator, it was revealed that the facility's Emergency Preparedness Plan failed to include all essential elements, including but not limited to, a comprehensive communication plan. The Administrator acknowledged the absence of documentation.
The new Administration stated that sections of the EPP (Emergency Preparedness Plan) were missing and could not be located due to change in staff.

Based on documentation and staff interview, the facility failed to comply with Emergency Preparedness Plan, develop and maintain comprehensive communication plan. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The finding included:

During documentation review and staff interview on 08/07/19 at 3:15 PM with the Administrator, it was revealed that the facility's Emergency Preparedness Plan failed to include all essential elements, including but not limited to, a comprehensive communication plan. Documents missing were medical doctor's telephone numbers, staff and volunteer contact information. The Administrator acknowledged the absence of the complete Emergency Preparedness Plan.
The new Administration stated that sections of the EPP (Emergency Preparedness Plan) were missing and could not be located due to change in staff.

Based on record review and interview, the facility failed to provide a communication plan in their Emergency Preparedness Program (EP) that includes the names and contact information of local emergency management officials and the ombudsman. This in the event of an emergency would leave residents vulnerable from the lack of assistance from outside agencies and support staffing.

The findings included:

On 08/07/19 at 2:45 PM while reviewing the facility's EP, there were no phone numbers in the contact list and communication plan for local emergency officials and the State Ombudsman. Concurrent with the review, the Administrator said that the communication plan would be updated.
The new Administration stated that sections of the EPP (Emergency Preparedness Plan) were missing and could not be located due to change in staff.

Based on written document review and staff interview, the facility failed to include all of the requirements that CMS Centers for Medicare & Medicaid Services require for the facility emergency plan and policies to meet code requirements. Documentation of training. This deficient practice affects all staff, visitors and all residents.

The findings included:

During staff interview and documentation review on 08/07/19 at 1:45 PM with the Administrator, the facility was not able to produce requested written documentation. Facility must maintain documentation of the annual training for all staff. The Administrator acknowledged the absence of documentation.
The new Administration stated that sections of the EPP (Emergency Preparedness Plan) were missing and could not be located due to change in staff.