Failure to Provide and Document Annual Emergency Preparedness Training
Penalty
Summary
The facility failed to provide initial and annual emergency preparedness training to all new and existing staff, individuals providing services under arrangement, and volunteers, as required by federal regulations. The deficiency was identified during a record review and interview with the facility education director, who confirmed that annual emergency preparedness refresher training had not been conducted as mandated by 42 CFR 483.73(d)(1)(2). No documentation was available to demonstrate that staff had received the required refresher training on emergency preparedness policies and procedures. The absence of such documentation indicated that the facility did not maintain records of emergency preparedness training for its staff, as required by regulation. Additionally, the facility was unable to demonstrate staff knowledge of emergency procedures, as there was no evidence that training had occurred. This deficiency could potentially affect all occupants in the event of an emergency, as staff may not be adequately prepared to respond to emergency situations.
Plan Of Correction
1. The facility failed to provide annual emergency preparedness refresher training to all facility employees. 2. Failure to provide the annual emergency preparedness refresher training to facility employees could affect all residents, employees, and visitors in the event of an emergency. 3. The education director has educated all employees on the emergency preparedness plan via the Relias education platform. The education director has been educated on the importance of the annual emergency preparedness refresher training. 4. The administrator is responsible for ensuring all employees are educated during the annual emergency refresher training and report to the QA committee.