Deficiency in Emergency Preparedness Training and Testing
Penalty
Summary
The facility was found to have a deficiency in its Emergency Preparedness (EP) program, specifically in the area of training and testing staff. During a review of the facility's EP Plan, it was discovered that the plan did not specify the type and frequency of training and testing required to ensure staff knowledge of emergency procedures. This lack of detail in the EP training and testing policy was identified during an interview and documentation review conducted on February 6, 2025. Further interviews with the Facility Administrator and Maintenance Director confirmed that the facility's EP plan was incomplete, as it did not include specific requirements for training and testing. This omission indicates that the facility failed to fully develop and maintain an EP program that meets regulatory standards, as it did not provide clear guidelines for staff training and testing to demonstrate their knowledge of emergency procedures.
Plan Of Correction
Facility trained staff on emergency procedures and tested staff on emergency procedures on March 21, 2025. Review of training and testing will be done on an annual basis by Administrator or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.