Deficiency in Emergency Preparedness Training Program
Penalty
Summary
The facility was found deficient in maintaining an emergency preparedness training program as required by regulations. During a document review on March 12, 2025, it was discovered that the facility failed to provide documentation of an emergency preparedness training program that is based on the Emergency Preparedness Plan. This program should include initial and annual training for all staff members, but the necessary documentation was not available. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed the facility's failure to develop an Emergency Preparedness Plan that includes a training program. This lack of documentation and development of a comprehensive training program indicates a significant oversight in the facility's emergency preparedness efforts.
Plan Of Correction
Facility conducted an annual in-service for staff on the emergency preparedness plan and training program. 4/28/25 Staff will be educated annually to remain in compliance. Director of maintenance will audit the emergency binder monthly x3 to ensure it is up to date.