The most cited Emergency Preparedness (EP) citation is E0041 – LTC (Long Term Care) Emergency Power. Out of 101 surveys conducted this year (2024) this tag was cited fifty-one times or (50.5 %).
The most common concerns and root causes of E0041 citation are the following:
- Missing weekly visual inspections
- Missing monthly run tests
- Not achieving 30% of capacity on every monthly run test or supplementing with an annual 1.5-hour load bank for diesel generators
- Missing 36-month four-hour load bank test
EP Testing Requirements – E0039 comes in second for most frequently cited EP tags. This tag was cited forty-two times out of 101 surveys or 41.6%. The requirements are as follows:
Documentation of testing is required in the last year, and the testing needs to be:
- Two community-based exercises
- One community based & one tabletop exercise.
- Have activated the plan.
The testing must be documented, have an after-action analysis, and must include a plan revision based on the after-action analysis.
Other top tags are as follows:
E004- Review and Update Emergency Preparedness Plan Annually
- The plan must be reviewed and updated at least annually.
- The annual review must be documented to include a date of the review, and any updates made to the emergency plan based on the review.
- A facility has discretion related to the format used to update the plan.
E0029 – Development of Communication Plan was cited for failure to maintain an emergency preparedness communication plan that complies with Federal and State, and local laws that was reviewed and updated at least every year in accordance with 42 CFR (Code of Federal Regulations) 483.4759 (c).
E0013 comes in at number five for failure to develop and/or implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of that section, risk assessment at paragraph (a)(1) and the communication plan at paragraph (c) of the section.
Email ldavenport@ihca.org if you have questions or need assistance with your emergency preparedness plan.