Gold Crest Care Center
February 7, 2018 Certification/complaint Survey

Standard Life Safety Code Citations

EP PROGRAM PATIENT POPULATION

REGULATION: [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a)(3):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 16, 2018
Corrected date: May 30, 2018

Citation Details

Based on emergency preparedness documentation review and staff interview, the facility did not ensure that its emergency preparedness (EP) program addressed its patient population. Reference is made to the lack of documentation. The findings are: On (MONTH) 16 (YEAR), between 9:30 am- 1:30 pm during the life safety recertification survey, the EP plan was thoroughly reviewed and the following components were not included: Address patient/client population, including, but not limited to, persons at- risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. There was no documentation provided to address the missing components. This was brought to the attention of the Administrator on (MONTH) 16 (YEAR), at approximately 1:45 pm during the exit conference. It was not clear to the surveyor as to what actions the facility will take to correct the situation.

Plan of Correction: ApprovedMarch 6, 2018

1. The Administrator reviewed the current emergency plan and identified the need of Address patient/client population, including, but not limited to, persons at- risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
. these areas will be revised, updated or added if identified to the emergency plan.
2. All residents have the potential to be affected by this deficient practice
3. The Administrator will use an audit tool to ensure compliance annually of theAddress patient/client population, including, but not limited to, persons at- risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
4. The Administrator will ensure compliance with an annual audit and negative findings will be corrected.

EP TRAINING AND TESTING

REGULATION: *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 16, 2018
Corrected date: May 30, 2018

Citation Details

Based on documentation review, the facility did not ensure that the emergency preparedness training and testing program were conducted. Reference is made to the lack of written emergency preparedness training materials, critiques following drills, or competency tests for facility staff. The findings are: On (MONTH) 16 (YEAR), between 9:30 am- 1:30 pm during the review of the Emergency Prepareness Plan, it was observed that the facility did not have a an emergency preparedness training and testing program. Reference is made to the lack of written emergency preparedness training materials, critiques following drills, or competency tests for facility staff. On (MONTH) 16 (YEAR), at approximately 1:45pm, this concern was discussed with the Administrator and it was not clear to the surveyor what corrective plan the facility will take.

Plan of Correction: ApprovedMarch 6, 2018

1. The Administrator reviewed the current emergency plan and identified the need to include emergency preparedness training materials, critiques following drills, or competency tests for facility staff.
2. All residents have the potential to be affected by this deficient practice
3. The Administrator will use an audit tool to ensure compliance annually to Include A mergency preparedness training materials, critiques following drills, or competency tests for facility staff.
4. The Administrator will ensure compliance with an annual audit and negative findings will be corrected.

ESTABLISHMENT OF THE EMERGENCY PROGRAM (EP)

REGULATION: The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must 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: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 16, 2018
Corrected date: May 30, 2018

Citation Details

Based on documentation review and staff interview, the facility did not ensure that a comprehensive emergency preparedness program that meets the Federal, State and local emergency preparedness requirements was established. Reference is made to the lack of written policies and procedures. The Findings are: On (MONTH) 16 (YEAR), at approximately 10:00 am, a review of the facility's Emergency Preparedness Comprehensive Plan was conducted and revealed that the facility did not establish an emergency preparedness program that met the Federal, State and local emergency preparedness requirements. The facility lacked written policies and procedures in the event of a disaster using an all hazards approach. In an interview with the Administrator on 2/16/18 at approximately 1:45 pm, he stated that he will establish comprehensive written policies and procedures for the health and safety of the residents in the event of a disaster using an all hazards approach.

Plan of Correction: ApprovedMarch 6, 2018

1. The Administrator reviewed the current emergency plan and identified areas in need of hazards approach. these areas will be revised, updated or added if identified to the emergency plan.
2. All residents have the potential to be affected by this deficient practice
3. The Administrator will use an audit tool to ensure compliance annually of the emergency plan hazards approach
4. The Administrator will ensure compliance with an annual audit and negative findings will be corrected.

INTEGRATED EP PROGRAM

REGULATION: (e) [or (f)]Integrated healthcare systems. If a [facility] is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the [facility] may choose to participate in the healthcare system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must- [do all of the following:] (1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program. (2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered. (3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program]. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following: (i) A documented community-based risk assessment, utilizing an all-hazards approach. (ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 16, 2018
Corrected date: May 30, 2018

Citation Details

Based on emergency preparedness documentation review and staff interview, the facility did not ensure that its emergency preparedness (EP) program addressed its integrated EP plan. Reference is made to the lack of documentation. The findings are: On (MONTH) 16 (YEAR), between 9:30 am- 1:30 pm during the life safety recertification survey, the EP plan was thoroughly reviewed and the following components were not included: Integrated healthcare systems. If a facility is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the facility may choose to participate in the healthcare system's coordinated emergency preparedness program. (1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program. (2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered. (3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance (with the program). (4) Include a unified and integrated emergency plan. The unified and integrated emergency plan must also be based on and include the following: (i) A documented community-based risk assessment, utilizing an all-hazards approach. (ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures. There was no documentation provided to address the missing components. On (MONTH) 16 (YEAR), at approximately 1:45 pm, this concern was discussed with the Administrator and it was not clear as what actions the facility will take.

Plan of Correction: ApprovedMarch 6, 2018

1. The Administrator reviewed the current emergency plan and identified that the facility is NOT part of integrated health system.
2. All residents have the potential to be affected by this deficient practice if the facility is part of an integrated health system.
3. The Administrator will use an audit tool to ensure compliance annually to Include that the facility is not part of an integrated health system
4. The Administrator will ensure compliance with an annual audit and negative findings will be corrected.

LOCAL, STATE, TRIBAL COLLABORATION PROCESS

REGULATION: [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years (annually for LTC facilities). The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 16, 2018
Corrected date: May 30, 2018

Citation Details

Based on emergency preparedness documentation review and staff interview, the facility did not ensure that its emergency preparedness (EP) program addressed emergency plan colloboration. Reference is made to the lack of documentation. The findings are: On (MONTH) 16 (YEAR), between 9:30 am- 1:30 pm during the life safety recertification survey, the EP plan was thoroughly reviewed and the following components were not included: Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. There was no documentation provided to address the missing components. On (MONTH) 16 (YEAR), at approximately 1:45 pm, the Administrator stated some of the documents are included in the plan.

Plan of Correction: ApprovedMarch 6, 2018

1. The Administrator reviewed the current emergency plan and identified the need to Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.
2. All residents have the potential to be affected by this deficient practice
3. The Administrator will use an audit tool to ensure compliance annually to Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.
4. The Administrator will ensure compliance with an annual audit and negative findings will be corrected.

PLAN BASED ON ALL HAZARDS RISK ASSESSMENT

REGULATION: [(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 LTC facilities at §483.73(a)(1):] 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)(1):] 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. * [For Hospices at §418.113(a)(2):] 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.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 16, 2018
Corrected date: May 30, 2018

Citation Details

Based on documentation review and staff interview, the facility did not ensure that a comprehensive risk assessment was conducted. The findings are: On (MONTH) 16 (YEAR), at approximately 11:00 am during the emergency preparedness review, the following was not included: Facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. In an interview with the Administrator on 2/16/18 at approximately 1:45 pm, he stated that he will establish a comprehensive risk assessment plan.

Plan of Correction: ApprovedMarch 6, 2018

1. The Administrator reviewed the current emergency plan and identified the need of Facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
. these areas will be revised, updated or added if identified to the emergency plan.
2. All residents have the potential to be affected by this deficient practice
3. The Administrator will use an audit tool to ensure compliance annually of the emergency plan hazards approach including missing residents.
4. The Administrator will ensure compliance with an annual audit and negative findings will be corrected.

POLICIES/PROCEDURES FOR MEDICAL DOCUMENTATION

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 16, 2018
Corrected date: May 30, 2018

Citation Details

Based on emergency preparedness documentation review and staff interview, the facility did not ensure that its emergency preparedness (EP) program addressed its Medical Documentation. Reference is made to the lack of documentation. The findings are: On (MONTH) 16 (YEAR), between 9:30 am- 1:30 pm during the life safety recertification survey, the EP plan was thoroughly reviewed and the following components were not included: A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. There was no documentation provided to address the missing components. This was brought to the attention of the Administrator on (MONTH) 16 (YEAR), at approximately 1:45 pm during the exit conference. It was not clear to the surveyor as to what actions the facility will take to correct the situation.

Plan of Correction: ApprovedMarch 6, 2018

1. The Administrator reviewed the current emergency plan and identified the need to AA system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
2. All residents have the potential to be affected by this deficient practice
3. The Administrator will use an audit tool to ensure compliance annually to Include A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
4. The Administrator will ensure compliance with an annual audit and negative findings will be corrected.

POLICIES/PROCEDURES FOR SHELTERING IN PLACE

REGULATION: (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 16, 2018
Corrected date: May 30, 2018

Citation Details

Based on emergency preparedness documentation review and staff interview, the facility did not ensure that its emergency preparedness (EP) program addressed its sheltering in place procedures. Reference is made to the lack of documentation. The findings are: On (MONTH) 16 (YEAR), between 9:30 am- 1:30 pm during the life safety recertification survey, the EP plan was thoroughly reviewed and the following components were not included: A means to shelter in place for patients, staff, and volunteers who remain in the facility. There was no documentation provided to address the missing components. On (MONTH) 16 (YEAR), at approximately 1:45 pm, Administrator stated that this concern will be addressed.

Plan of Correction: ApprovedMarch 6, 2018

1. The Administrator reviewed the current emergency plan and identified the need to A means to shelter in place for patients, staff, and volunteers who remain in the facility.
2. All residents have the potential to be affected by this deficient practice
3. The Administrator will use an audit tool to ensure compliance annually to Include A means to shelter in place for patients, staff, and volunteers who remain in the facility.
4. The Administrator will ensure compliance with an annual audit and negative findings will be corrected.

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 16, 2018
Corrected date: May 30, 2018

Citation Details

Based on emergency preparedness documentation review and staff interview, the facility did not ensure that its emergency preparedness (EP) program addressed volunteers. Reference is made to the lack of documentation. The findings are: On (MONTH) 16 (YEAR), between 9:30 am- 1:30 pm during the life safety recertification survey, the EP plan was thoroughly reviewed and the following components were not included: The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. On (MONTH) 16 (YEAR), at approximately 1:45 pm, the Administrator stated that this concern will be addressed.

Plan of Correction: ApprovedMarch 6, 2018

1. The Administrator reviewed the current emergency plan and identified the need to Ahe use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
2. All residents have the potential to be affected by this deficient practice
3. The Administrator will use an audit tool to ensure compliance annually to Include A he use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
4. The Administrator will ensure compliance with an annual audit and negative findings will be corrected.

SUBSISTENCE NEEDS FOR STAFF AND PATIENTS

REGULATION: [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years (annually for LTC). At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 16, 2018
Corrected date: May 30, 2018

Citation Details

Based on emergency preparedness documentation review and staff interview, the facility did not ensure that its emergency preparedness (EP) program addressed its subsistence needs. Reference is made to the lack of documentation. The findings are: On (MONTH) 16 (YEAR), between 9:30 am- 1:30 pm during the life safety recertification survey, the EP plan was thoroughly reviewed and the following components were not included: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. There was no documentation provided to address the missing components. On (MONTH) 16 (YEAR), at approximately 1:45 pm, this concern was brought to the attention of the Administrator and he stated that all parts of this requirement will be maintained.

Plan of Correction: ApprovedMarch 6, 2018

1. The Administrator reviewed the current emergency plan and identified the need to (A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
2. All residents have the potential to be affected by this deficient practice
3. The Administrator will use an audit tool to ensure compliance annually to Include(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
4. The Administrator will ensure compliance with an annual audit and negative findings will be corrected.