Deficiency in Emergency Preparedness Training Program
Penalty
Summary
The facility was found to be deficient in developing and maintaining an emergency preparedness training and testing program based on its emergency preparedness plan. During a document review on December 23, 2024, it was revealed that the facility had not established a training and testing program that aligns with the emergency plan, risk assessment, policies and procedures, and communication plan as required. This deficiency affects the entire facility, indicating a lack of compliance with the annual review and update requirement for the training and testing program. An exit interview with the Assistant Administrator and the Maintenance Director confirmed the absence of a comprehensive training and testing program. The failure to implement such a program suggests that the facility did not adhere to the regulatory requirements for emergency preparedness, which mandates an annual review and update. This oversight was identified through documentation review and interviews, highlighting a significant gap in the facility's emergency preparedness efforts.
Plan Of Correction
Emergency preparedness plan has been reviewed and updated to include the EPP training and testing staff based on the emergency plan. Maintenance Dir/designee will re-educate maintenance staff on timely updates for policies and procedures relating to training and testing staff based on the emergency plan. NHA/designee will complete weekly audits x1 and monthly x2 to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.