Deficiency in Emergency Preparedness Training Documentation
Penalty
Summary
The facility was found to have deficiencies in its Emergency Preparedness (EP) Training Program. During a review of the facility's EP Plan, it was discovered that the facility failed to maintain documentation of staff training and testing. Specifically, the facility could not provide documentation for maintaining records of all emergency preparedness training and demonstrating staff knowledge of emergency procedures. On December 30, 2024, an interview and documentation review revealed that the facility did not have records of an annual tabletop exercise of the Emergency Preparedness program. This lack of documentation indicates that the facility did not comply with the requirement to maintain records of all emergency preparedness training activities. The deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director on the same day. They acknowledged the absence of the necessary documentation for the EP training and testing, which is a critical component of ensuring staff readiness in emergency situations.
Plan Of Correction
Preparation and submission does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness set forth in the statement of deficiencies. The plan of correction is prepared and submitted solely because of the requirements under state and the federal laws. The NHA will be educated on the Emergency Preparedness Training Program annual tabletop exercise requirement. The facility will conduct a tabletop exercise of the Emergency Preparedness Program.