Deficiency in Emergency Preparedness Training Program
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.
Penalty
Surveyors found that the facility failed to maintain documentation of initial and annual emergency preparedness training for all new and existing staff. Interviews with the Administrator and Maintenance Director confirmed that required training records were not kept, resulting in a deficiency related to emergency preparedness training documentation.
The facility did not provide or document required initial and annual emergency preparedness training for all staff, individuals providing services under arrangement, and volunteers. An interview with the education director confirmed the lack of annual refresher training and absence of documentation, resulting in noncompliance with federal emergency preparedness regulations.
The facility failed to maintain documentation of initial and annual Emergency Preparedness training for staff and volunteers, as revealed during a document review and confirmed in an exit interview with the Administrator and Director of Maintenance.
The facility failed to maintain documentation of emergency preparedness training for all new and existing staff, as revealed during a review of the EP Plan. Interviews with the Facility Administrator and Maintenance Director confirmed the lack of documentation, indicating non-compliance with regulatory requirements.
The facility failed to maintain documentation of initial and annual Emergency Preparedness training for staff and volunteers, affecting the entire facility. A document review revealed the absence of records demonstrating staff knowledge of emergency procedures, confirmed by the Executive Director during an exit interview.
The facility failed to maintain documentation of staff training and testing for their Emergency Preparedness Plan, affecting the entire facility. This deficiency was confirmed through interviews with the Facility Administrator and Maintenance Director, highlighting a lack of adherence to regulatory requirements for emergency preparedness training.
Failure to Maintain Documentation of Emergency Preparedness Training
Penalty
Summary
Surveyors identified a deficiency related to the facility's Emergency Preparedness (EP) training program. During a review of the facility's EP Plan and associated documentation, it was found that the facility did not maintain records of initial and annual emergency preparedness training for all new and existing staff. This lack of documentation was discovered during an interview and documentation review conducted on July 7, 2025, at 9:00 a.m. Further interviews with the Facility Administrator and the Maintenance Director confirmed that the required training documentation was not maintained. The absence of these records means there was no evidence to demonstrate that staff, individuals providing services under arrangement, and volunteers received the necessary initial and annual EP training as required by federal regulations. No specific residents or patient cases were mentioned in the report, and there were no details provided regarding the medical history or condition of any individuals at the time of the deficiency. The deficiency centers solely on the facility's failure to document and maintain records of emergency preparedness training for its personnel.
Plan Of Correction
Documentation of staff Emergency Preparedness Training and Testing is now present in the facility. The Maintenance Director/designee has completed and will continue to complete initial and annual Emergency Preparedness Training and Testing for all new and existing staff. The Facility Administrator will ensure compliance by confirming the Emergency Preparedness Training and Testing documentation of initial and annual training for all new and existing staff is maintained by checking monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings.
Failure to Provide and Document Annual Emergency Preparedness Training
Penalty
Summary
The facility failed to provide initial and annual emergency preparedness training to all new and existing staff, individuals providing services under arrangement, and volunteers, as required by federal regulations. The deficiency was identified during a record review and interview with the facility education director, who confirmed that annual emergency preparedness refresher training had not been conducted as mandated by 42 CFR 483.73(d)(1)(2). No documentation was available to demonstrate that staff had received the required refresher training on emergency preparedness policies and procedures. The absence of such documentation indicated that the facility did not maintain records of emergency preparedness training for its staff, as required by regulation. Additionally, the facility was unable to demonstrate staff knowledge of emergency procedures, as there was no evidence that training had occurred. This deficiency could potentially affect all occupants in the event of an emergency, as staff may not be adequately prepared to respond to emergency situations.
Plan Of Correction
1. The facility failed to provide annual emergency preparedness refresher training to all facility employees. 2. Failure to provide the annual emergency preparedness refresher training to facility employees could affect all residents, employees, and visitors in the event of an emergency. 3. The education director has educated all employees on the emergency preparedness plan via the Relias education platform. The education director has been educated on the importance of the annual emergency preparedness refresher training. 4. The administrator is responsible for ensuring all employees are educated during the annual emergency refresher training and report to the QA committee.
Failure to Document Emergency Preparedness Training
Penalty
Summary
The facility was found to be deficient in maintaining documentation of initial and annual Emergency Preparedness training for staff and individuals providing services, including volunteers. This deficiency was identified during a document review conducted on March 12, 2025, at 3:15 p.m. The review revealed that the facility failed to provide maintained annual documentation of Emergency Preparedness training for staff members, which is necessary to demonstrate their knowledge of emergency procedures. The deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day. The interview corroborated the findings that the facility did not have the required annual records of employee training in emergency preparedness. This lack of documentation indicates a failure to comply with the regulatory requirement to provide and document such training annually. The report does not mention any specific incidents involving patients or any immediate consequences resulting from this deficiency. The focus is solely on the facility's failure to maintain proper records of emergency preparedness training, which is a critical component of ensuring staff readiness in emergency situations.
Plan Of Correction
1. Facility conducted an annual in-service for staff on the emergency preparedness plan. 2. 4/28/25 3. Staff will be educated annually to remain in compliance. 4. Director of maintenance will audit the emergency binder monthly x3 to ensure it is up to date 8/25. Director will keep record in maintenance binder.
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.
Deficiency in Emergency Preparedness Training Documentation
Penalty
Summary
The facility was found to be deficient in maintaining documentation of initial and annual Emergency Preparedness training for staff, individuals providing services, and volunteers. During a document review conducted on January 21, 2025, it was revealed that the facility failed to provide the required documentation demonstrating that staff members had received the necessary training in emergency procedures. This deficiency affected the entire facility, indicating a systemic issue in the training program. The surveyors noted that the facility did not have records to confirm that staff and service providers were knowledgeable about emergency procedures, as required by the regulations. The lack of documentation suggests that the facility did not conduct or properly record the training sessions, which are essential for ensuring that all personnel are prepared to respond effectively in emergency situations. An exit interview with the Executive Director of Construction and Ancillary Services confirmed the absence of annual records of employee training. This acknowledgment by the facility's leadership further substantiates the deficiency, highlighting a failure in the facility's compliance with emergency preparedness training requirements.
Plan Of Correction
1) EPP Inservice of staff to be completed. 2) ED of construction to Inservice supervisor of plant operations on EPP training program policy and procedure. 3) Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to ensure compliance. Audit findings will be monthly for further review and recommendations as needed. Further audits frequency will be determined based on the outcome of the previously completed audit findings.
Deficiency in Emergency Preparedness Training Documentation
Penalty
Summary
The facility was found to be deficient in maintaining documentation of staff training and testing related to their Emergency Preparedness (EP) Plan. During a review conducted on January 21, 2025, it was discovered that the facility failed to provide the necessary documentation for sections (iii) and (iv) of the EP Training Program. This deficiency affected the entire facility, indicating a systemic issue in the documentation process. The deficiency was confirmed through an interview with the Facility Administrator and the Maintenance Director on the same day. They acknowledged the lack of documentation for the required emergency preparedness training and testing. This failure to maintain proper records suggests that the facility did not adhere to the regulatory requirements for emergency preparedness training, which mandates maintaining documentation and demonstrating staff knowledge of emergency procedures. The report does not provide specific details about any patients or residents affected by this deficiency, nor does it mention any immediate consequences or risks posed by the lack of documentation. The focus of the deficiency is on the facility's failure to comply with the documentation requirements for emergency preparedness training, which is a critical component of ensuring staff readiness in emergency situations.
Plan Of Correction
1. The required Bi-annual EP training was completed on 1/22/25 with staff. 2. There is only one required Fed EP; therefore, no additional reviews were needed. 3. The Executive Director will educate the Maintenance Director and Director of Clinical Services on the importance of 42 CFR 483.73- ΕΡ training and properly documenting the trainings. This will also be added to new hire trainings. 4. This will continue to be monitored; any findings will be reported to the monthly QAPI Committee for further review.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.