Failure to Provide Annual Emergency Preparedness Training to All Staff and Volunteers
Penalty
Summary
The facility failed to provide annual emergency preparedness training to all staff and volunteers as required by federal regulations. During a document review, it was found that there was no documentation confirming that all staff and volunteers had received the required annual emergency preparedness training based on the facility's emergency preparedness plan. An interview with the administrator and maintenance supervisor confirmed the absence of documentation verifying that all staff and volunteers had completed the annual emergency preparedness training. This lack of documentation indicated noncompliance with the requirement to maintain an up-to-date emergency preparedness training and testing program for all personnel.
Plan Of Correction
E 0036 The systematic change will be an emergency preparedness training will be held so all employees receive the required training for stated deficiency. The Administrator or designee will monitor the training to make sure it occurs and all employees have signed off receiving the training. An annual training will then be established so all employees received the Emergency Preparedness training required. Monthly Quality Assurance meeting will review training guidelines. Education will be completed by January 31, 2026.