Deficiency in Emergency Preparedness Training Documentation
Penalty
Summary
Kittanning Health and Rehab Center was found to have a deficiency related to emergency preparedness training and testing as per the requirements of 42 CFR 483.73. During an emergency preparedness survey conducted on January 22, 2025, it was discovered that the facility failed to provide documentation proving that all staff had received the required annual emergency preparedness training and testing within the previous twelve months. This lack of documentation was confirmed during an interview with the maintenance supervisor. The deficiency was identified through a document review and an interview conducted on the same day. The absence of documentation indicates that the facility did not adhere to the regulatory requirement to maintain an updated emergency preparedness training and testing program. This oversight suggests a lapse in ensuring that staff are adequately prepared for emergency situations, although the report does not specify any immediate consequences or risks resulting from this deficiency.
Plan Of Correction
The Emergency Preparedness Plan (EPP) was reviewed and updated as necessary. The Emergency Preparedness Plan is to be reviewed and updated at least annually based on the most recent documented, facility-based and community-based risk assessment using an all-hazards approach. NHA/designee to complete annual full-scale exercise/table-top exercise by 21MAR2025. NHA/designee to educate all staff by 21MAR2025 on the Emergency Preparedness Plan and annual testing requirements to ensure a comprehensive understanding of policies and procedures and staff readiness. RVPO/designee to educate NHA by 21MAR2025 on the requirements of Emergency Preparedness Plan Guidelines and staff annual EPP training requirements. To prevent this from recurring, RVPO will complete annual audits on facility EPP to ensure current updated version. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendation.