Failure to Maintain Documentation of Emergency Preparedness Training
Penalty
Summary
Surveyors identified a deficiency related to the facility's Emergency Preparedness (EP) training program. During a review of the facility's EP Plan and associated documentation, it was found that the facility did not maintain records of initial and annual emergency preparedness training for all new and existing staff. This lack of documentation was discovered during an interview and documentation review conducted on July 7, 2025, at 9:00 a.m. Further interviews with the Facility Administrator and the Maintenance Director confirmed that the required training documentation was not maintained. The absence of these records means there was no evidence to demonstrate that staff, individuals providing services under arrangement, and volunteers received the necessary initial and annual EP training as required by federal regulations. No specific residents or patient cases were mentioned in the report, and there were no details provided regarding the medical history or condition of any individuals at the time of the deficiency. The deficiency centers solely on the facility's failure to document and maintain records of emergency preparedness training for its personnel.
Plan Of Correction
Documentation of staff Emergency Preparedness Training and Testing is now present in the facility. The Maintenance Director/designee has completed and will continue to complete initial and annual Emergency Preparedness Training and Testing for all new and existing staff. The Facility Administrator will ensure compliance by confirming the Emergency Preparedness Training and Testing documentation of initial and annual training for all new and existing staff is maintained by checking monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings.