Failure to Document Emergency Preparedness Training
Penalty
Summary
The facility was found to be deficient in maintaining documentation of emergency preparedness (EP) training for its staff. During a review of the facility's EP Plan, it was discovered that there was a lack of documentation for both initial and annual training for all new and existing staff. This deficiency was identified during an interview and documentation review conducted on February 6, 2025, at 9:20 a.m. Further investigation involved an interview with the Facility Administrator and the Maintenance Director on the same day at 1:00 p.m. During this interview, it was confirmed that the facility had not maintained the necessary documentation of the EP training. This lack of documentation indicates a failure to comply with the regulatory requirements for emergency preparedness training. The deficiency highlights the facility's failure to ensure that all staff, including those providing services under arrangement and volunteers, received the required initial and annual training in emergency preparedness policies and procedures. The absence of documentation also suggests that the facility may not be able to demonstrate staff knowledge of emergency procedures, as required by the regulations.
Plan Of Correction
Facility will review new hire training and annual training to include Emergency Preparedness. Annual training for emergency preparedness will be completed by March 3/21/2025. A monthly audit of new hire training courses on emergency preparedness will be completed by the Administrator or designee for completion. On an annual basis, an audit will be conducted by the Administrator or designee for completion of the emergency preparedness training. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.