Deficiency in Emergency Preparedness Training Program
Penalty
Summary
Monumental Post-Acute Care at Woodside Park was found to have deficiencies in its Emergency Preparedness Training program during a survey conducted on January 22, 2025. The survey revealed that the facility failed to develop a comprehensive training program based on its emergency plan, risk assessment, policies and procedures, and communication plan. This deficiency affected the entire facility, as it did not include written policies and procedures identifying the training program for all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. The documentation reviewed during the survey indicated that the Emergency Preparedness plan lacked the necessary written policies and procedures for training. This omission was confirmed during an exit interview with the Facility Administrator and Maintenance Director. The absence of a structured training program meant that the facility did not meet the requirements set forth in 42 CFR 483.73, which mandates initial and ongoing training in emergency preparedness for all relevant personnel. The deficiency was identified through a combination of document review and interviews with facility staff. The lack of a documented training program suggests that the facility did not adequately prepare its staff and volunteers for emergency situations, potentially impacting their ability to respond effectively in such events. However, the report does not provide specific details about any incidents or patient outcomes related to this deficiency.
Plan Of Correction
MPAC has an Ep plan which includes education and training of Staff on Hire and annually. Maintenance Director and team will be re-in-serviced BY nha on MPAC Emergency Preparedness' Plan. The Maintenance Director or Designee will conduct random Drills/quizzes monthly to ensure Staff are aware of and follow MPAC EP guidelines during emergencies. Results of Random Drills will be reported in Monthly QAPI.