42 CFR483.41 (a) Nursing Home The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This is a recertification survey for Medicare under LSC 2012, Chapter 19 existing nursing home. The entire facility was surveyed on October 17, 2023. The facility meets the standards, based upon compliance with all provisions of the standards No apparent deficiencies were found during the survey.
Federal Comments
42 CFR 483.73 Long Term Care Facilities. The facility must meet all applicable Federal, State and local emergency preparedness requirements as outlined in the Medicare and Medicaid Programs: Emergency Preparedness Requirements of Medicare and Medicaid Participating Providers and Suppliers Final Rule (81 FR 63860) September 16, 2016. The facility meets the standards, based upon acceptance of a plan of corrections. 42 CFR483.41 (a) Nursing Home The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This is a recertification survey for Medicare under LSC 2012, Chapter 19 existing nursing home. The entire facility was surveyed on October 17, 2023. The facility meets the standards, based upon compliance with all provisions of the standards No apparent deficiencies were found during the survey.
Statement of Deficiency
1 deficiency found
Deficiency #1
✓ Plan Provided
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Rule
(2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following: *[For LTC Facilities at §483.73(d):] (2) Testing. The LTC facility must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The LTC facility must do all of the following:] (i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event. (ii) Conduct an additional exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based. (B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For RNHCIs at §403.748 and OPOs at §486.360] (d)(2) Testing. The [RNHCI and OPO] must conduct exercises to test the emergency plan. The [RNHCI and OPO] must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emer
Evidence
Based on record review and staff interview, the facility failed to participate in a full scale community based exercise in 2022-2023. Failure to provide policy and procedures for the training and testing program may lead to untrained staff in an emergency situation and may result in harm to patients and/or staff during an emergency. Findings include; Based on record review and staff interview October 17, 2023, revealed the facility failed to provide documentation of participation for the following; 1) Participate in a full-scale exercise (FSE) that is community-based. 2) Conduct an additional exercise that may include, but is not limited to the following: (A) A second FSE that is individual, facility-based. (B) A tabletop exercise. During the exit conference on October 17, 2023, the above finding was again acknowledge by the management team.