Failure to Annually Update Emergency Preparedness Training and Testing
Penalty
Summary
The facility failed to maintain its Emergency Preparedness Plan (EPP) as required by federal regulations. During a document review and staff interview, it was found that there were no documents available to show that the Emergency Preparedness (EP) training and testing program for new and existing staff had been reviewed or updated at least annually. The last date of training and testing review was unknown, and staff confirmed that the EP training and testing had not yet been updated. This deficiency was identified during a review of the facility's documentation and through interviews with staff. The lack of updated EP training and testing could affect all 92 residents in the facility, as there was no evidence that staff were adequately prepared according to the required schedule. The findings are based on direct observations and interviews conducted by surveyors.
Plan Of Correction
How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The EVS Director or designee will conduct quarterly audits of the Communication Plan to ensure it remains updated. The results of these audits will be reported during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. Any deficiencies identified during audits will be addressed immediately, and corrective actions will be documented. Date of Compliance 4/18/25 E 036: EP Training and Testing How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The facility initiated a review and update of the Training and Testing Plan upon identification of the deficiency. The facility's leadership and emergency preparedness team have reviewed the updated plan on 4/9/25. The testing was conducted on 4/10/25 by the EVS Director. A training was done on 4/10/25 by the EVS Director. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents have the potential to be affected. The facility will update the Training and Testing Plan to ensure all protocols for the protection of all residents during emergencies. An audit will be conducted on 4/10/25 to verify that the Training and Testing Plan is up to date. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur; The facility has established a process to review and update the Training and Testing Plan annually. The policy now requires the administrator or designee to document the annual review in a designated log. An emergency plan test will be conducted twice a year by the EVS Director. A training will be done once a year by the EVS Director. A calendar reminder has been set for December 1st of each year to ensure timely review and update of the Training and Testing Plan by the new year. The facility's emergency preparedness committee will convene quarterly to review the Training and Testing Plan and make any necessary revisions. The EVS Director was retrained on the importance of maintaining an updated Training and Testing Plan, by the Administrator on 4/9/25. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The EVS Director or designee will conduct quarterly audits of the Training and Testing Plan to ensure it remains updated. The results of these audits will be reported during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. Any deficiencies identified during audits will be addressed immediately, and corrective actions will be documented.