Failure to Provide Annual Emergency Preparedness Training to Staff
Penalty
Summary
The facility failed to provide required Emergency Preparedness training to six out of seven reviewed staff members, including five nurse aides and one LPN. According to the facility's own policy, all staff, contractors, and volunteers must complete training on emergency preparedness prior to independently providing services, annually, and as needed based on the facility assessment. Personnel file reviews for these six employees showed no documentation of Emergency Preparedness training within the required annual period following their respective hire dates. This deficiency was confirmed during an interview with a Human Resources employee, who acknowledged that the required training had not been provided to these staff members. The lack of documented training was identified through a review of facility policies, staff files, and direct staff interviews.
Plan Of Correction
Employee's 4, 5, 6, 7, 8, and 9 will receive the Emergency Preparedness training in January 2026. All employees will receive an annual Emergency Preparedness training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Emergency Preparedness training. Human resource Director or designee will audit the training to assure all staff have been educated on Emergency Preparedness training topic. Audit results will be turned into Quality Assurance meeting monthly.