Failure to Document Emergency Preparedness Training
Penalty
Summary
The facility was found to be deficient in maintaining documentation of initial and annual Emergency Preparedness training for staff and individuals providing services, including volunteers. This deficiency was identified during a document review conducted on March 12, 2025, at 3:15 p.m. The review revealed that the facility failed to provide maintained annual documentation of Emergency Preparedness training for staff members, which is necessary to demonstrate their knowledge of emergency procedures. The deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day. The interview corroborated the findings that the facility did not have the required annual records of employee training in emergency preparedness. This lack of documentation indicates a failure to comply with the regulatory requirement to provide and document such training annually. The report does not mention any specific incidents involving patients or any immediate consequences resulting from this deficiency. The focus is solely on the facility's failure to maintain proper records of emergency preparedness training, which is a critical component of ensuring staff readiness in emergency situations.
Plan Of Correction
1. Facility conducted an annual in-service for staff on the emergency preparedness plan. 2. 4/28/25 3. Staff will be educated annually to remain in compliance. 4. Director of maintenance will audit the emergency binder monthly x3 to ensure it is up to date 8/25. Director will keep record in maintenance binder.