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.