Failure to Maintain Emergency Preparedness Training and Testing Program
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness training and testing program for staff, as required by federal regulations. During a record review and interview with the Maintenance Director and Administrator, surveyors found that the facility could not provide the policy and procedure related to emergency preparedness training and testing. The Administrator was unaware that the policy was missing and indicated she would need to investigate the reason for its absence. This deficiency affected all 120 residents in the facility, as the lack of a documented and maintained emergency preparedness training and testing program meant that staff were not adequately prepared according to regulatory requirements. The facility was given an opportunity to submit the missing records by a specified deadline, but no records were received by the survey agency.
Plan Of Correction
E036 - Emergency Preparedness Training and Testing 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/09/2025, the facility conducted an Emergency Preparedness training for all staff and completed a tabletop exercise to simulate emergency response procedures. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/09/2025, the facility implemented an annual Emergency Preparedness training and testing calendar and established a system for tracking staff participation. On 05/09/25, the Maintenance Director educated by the Administrator on the requirements and documentation for Emergency Preparedness Training. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of training logs and exercise documentation to ensure all staff are trained and drills are conducted annually. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved. 05/15/25 E 036