Failure to Develop Emergency Preparedness Training Program
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness training and testing program based on its emergency preparedness plan. This deficiency was identified during a document review conducted on November 20, 2024, at 8:00 a.m. The review revealed that the facility did not have the necessary documentation to support the existence of such a program. This issue affects the entire facility, as confirmed during an exit interview with the Administrator and the Maintenance Director on the same day. A follow-up onsite revisit on January 8, 2025, between 12:00 p.m. and 12:30 p.m., confirmed that the facility still had not developed or maintained the required emergency preparedness training and testing program. The lack of documentation was again confirmed during an exit interview with the Administrator and the Regional Maintenance Director at 12:45 p.m. on the same day. This ongoing deficiency indicates a failure to comply with the regulatory requirement to review and update the program at least annually.
Plan Of Correction
Plan of Correction for TAG E0036: Emergency Preparedness Training and Testing 1. Deficiency: Based on documentation review and interview, it was determined that the facility failed to develop an emergency preparedness training program that is based on the facility's emergency preparedness plan. The training and testing program must be reviewed and updated at least annually, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed the facility failed to develop and maintain an emergency preparedness training and testing program that aligns with the emergency preparedness plan. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of documentation. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected if the facility's staff is not properly trained in emergency preparedness protocols. 2. Corrective Action: The facility will develop and implement an emergency preparedness training program based on the facility's updated emergency preparedness plan. The training program will include testing procedures and will be reviewed and updated at least annually to ensure ongoing compliance. 3. Monitoring: The facility will track and document all training sessions, including the participation of all relevant staff members. An annual review of the training program will be conducted to ensure that it remains aligned with the current emergency preparedness plan and includes all necessary updates. 4. Timeline: The emergency preparedness training program will be developed and implemented by 01/28/25, with annual reviews thereafter.