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.