Deficiency in Emergency Preparedness Training
Summary
During a Standard Life Safety Code Survey, it was found that the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan and Training Program lacked instruction and a demonstration of knowledge, such as a quiz, on the most likely hazards identified by the risk assessment. These hazards included tropical storms, blizzards, floods, thunderstorms, snow, and communication failures. There was no documented evidence that the Emergency Preparedness Plan included training and a demonstration of knowledge for these hazards. During an interview, a Nurse Senior Educator acknowledged the omission and stated that they would update the Emergency Preparedness Plan to include the necessary training and demonstration of knowledge.
Plan Of Correction
Plan of Correction: Approved May 3, 2025 Element 1 The Emergency Plan was updated to include training on the hazards rated most likely. The plan was updated to more correctly reflect the hazards the facility is most at risk to experience. The updated plan includes training for the following: Blizzard, Thunderstorm, Snow, Communication Failure. Element 2 All residents have potential to be impacted. Element 3 The Emergency preparedness education plan was updated to include training on the hazards most likely based on the facility hazard vulnerability assessment. The nurse educator will provide education to staff regarding the high-risk areas. Annually, as part of the facility assessment review, the All hazards assessment will be reviewed. Any changes in identified risks will be added to the education plan. Element 4 Results of the education will be presented to the Facility Quality Assurance Committee at the monthly meeting. The committee will make recommendations for ongoing frequency and any need for change in plan, education, or policy based on results of review. The Executive Director is responsible for ongoing compliance.
Penalty
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