Failure to Develop Emergency Preparedness Training Program
Summary
The facility failed to develop and maintain an emergency preparedness training and testing program based on its emergency preparedness plan. This deficiency was identified during a document review conducted on November 20, 2024, at 8:00 a.m. The review revealed that the facility did not have the necessary documentation to support the existence of such a program. This issue affects the entire facility, as confirmed during an exit interview with the Administrator and the Maintenance Director on the same day. A follow-up onsite revisit on January 8, 2025, between 12:00 p.m. and 12:30 p.m., confirmed that the facility still had not developed or maintained the required emergency preparedness training and testing program. The lack of documentation was again confirmed during an exit interview with the Administrator and the Regional Maintenance Director at 12:45 p.m. on the same day. This ongoing deficiency indicates a failure to comply with the regulatory requirement to review and update the program at least annually.
Plan Of Correction
Plan of Correction for TAG E0036: Emergency Preparedness Training and Testing 1. Deficiency: Based on documentation review and interview, it was determined that the facility failed to develop an emergency preparedness training program that is based on the facility's emergency preparedness plan. The training and testing program must be reviewed and updated at least annually, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed the facility failed to develop and maintain an emergency preparedness training and testing program that aligns with the emergency preparedness plan. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of documentation. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected if the facility's staff is not properly trained in emergency preparedness protocols. 2. Corrective Action: The facility will develop and implement an emergency preparedness training program based on the facility's updated emergency preparedness plan. The training program will include testing procedures and will be reviewed and updated at least annually to ensure ongoing compliance. 3. Monitoring: The facility will track and document all training sessions, including the participation of all relevant staff members. An annual review of the training program will be conducted to ensure that it remains aligned with the current emergency preparedness plan and includes all necessary updates. 4. Timeline: The emergency preparedness training program will be developed and implemented by 01/28/25, with annual reviews thereafter.
Penalty
The facility did not provide or document annual emergency preparedness training for all staff and volunteers, as confirmed by both document review and interviews with facility leadership.
Surveyors identified that the facility did not provide evidence of an annual update to its emergency preparedness plan (EPP) training and testing program. The last documented review was in 2023, and staff confirmed no subsequent update had occurred, resulting in noncompliance with regulatory requirements for emergency preparedness.
Surveyors found that the facility did not have a documented emergency preparedness training and testing program for staff, and the Administrator was unaware of the missing policy. This deficiency affected all residents, as the required records were not provided when requested.
Surveyors found that the facility did not provide documentation showing that its Emergency Preparedness (EP) training and testing program for staff had been reviewed or updated on an annual basis. Staff confirmed that the EP training and testing had not been updated, and the last review date was unknown, affecting all residents.
The facility failed to maintain an emergency preparedness training program based on the Emergency Preparedness Plan, lacking documentation of initial and annual staff training. This was confirmed during an exit interview with the Administrator and other staff.
The facility was found deficient in its Emergency Preparedness (EP) program due to a lack of specified training and testing requirements. A review revealed that the EP plan did not indicate the type and frequency of training needed to ensure staff knowledge of emergency procedures. Interviews with the Facility Administrator and Maintenance Director confirmed the absence of these requirements in the EP plan.
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.
Failure to Annually Update Emergency Preparedness Training and Testing Program
Penalty
Summary
The facility failed to maintain compliance with emergency preparedness requirements by not updating its emergency preparedness plan (EPP) training and testing program on an annual basis. During a record review and interview with staff, it was found that the last update to the EPP training and testing program occurred in November 2023, and no subsequent annual update was provided as required. Staff confirmed that the most recent review date was in 2023, indicating that the program had not been reviewed or updated within the required timeframe. This deficiency was identified during a survey in which the facility was unable to produce documentation of an updated EPP training and testing program. The lack of an annual update could affect the facility's ability to ensure proper planning and preparation for emergencies for all 90 residents. The findings were based solely on the absence of the required annual review and update of the emergency preparedness training and testing program.
Plan Of Correction
The facility recognizes the importance of developing and maintaining an emergency preparedness training and testing program. The facility shall continue to provide an EPP training and testing program update annually. The Emergency preparedness training and testing program shall be reviewed June 26, 2025 during the QA Committee meeting. The emergency training and testing program shall be included in the annual review of facility policy and procedures in January 2026 and then each year consecutively in the following January. Further issues regarding the training and testing program of the EPP shall be received during the QA process and brought to the QAPI Committee for review and discussion at least quarterly, or more frequent if necessary. The Administrator, Environmental Services Supervisor, QA Manager, and DON shall be responsible for monitoring and ongoing compliance. This page is purposefully left blank. This page is purposefully left blank.
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
Failure to Annually Update Emergency Preparedness Training and Testing
Penalty
Summary
The facility failed to maintain its Emergency Preparedness Plan (EPP) as required by federal regulations. During a document review and staff interview, it was found that there were no documents available to show that the Emergency Preparedness (EP) training and testing program for new and existing staff had been reviewed or updated at least annually. The last date of training and testing review was unknown, and staff confirmed that the EP training and testing had not yet been updated. This deficiency was identified during a review of the facility's documentation and through interviews with staff. The lack of updated EP training and testing could affect all 92 residents in the facility, as there was no evidence that staff were adequately prepared according to the required schedule. The findings are based on direct observations and interviews conducted by surveyors.
Plan Of Correction
How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The EVS Director or designee will conduct quarterly audits of the Communication Plan to ensure it remains updated. The results of these audits will be reported during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. Any deficiencies identified during audits will be addressed immediately, and corrective actions will be documented. Date of Compliance 4/18/25 E 036: EP Training and Testing How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The facility initiated a review and update of the Training and Testing Plan upon identification of the deficiency. The facility's leadership and emergency preparedness team have reviewed the updated plan on 4/9/25. The testing was conducted on 4/10/25 by the EVS Director. A training was done on 4/10/25 by the EVS Director. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents have the potential to be affected. The facility will update the Training and Testing Plan to ensure all protocols for the protection of all residents during emergencies. An audit will be conducted on 4/10/25 to verify that the Training and Testing Plan is up to date. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur; The facility has established a process to review and update the Training and Testing Plan annually. The policy now requires the administrator or designee to document the annual review in a designated log. An emergency plan test will be conducted twice a year by the EVS Director. A training will be done once a year by the EVS Director. A calendar reminder has been set for December 1st of each year to ensure timely review and update of the Training and Testing Plan by the new year. The facility's emergency preparedness committee will convene quarterly to review the Training and Testing Plan and make any necessary revisions. The EVS Director was retrained on the importance of maintaining an updated Training and Testing Plan, by the Administrator on 4/9/25. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The EVS Director or designee will conduct quarterly audits of the Training and Testing Plan to ensure it remains updated. The results of these audits will be reported during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. Any deficiencies identified during audits will be addressed immediately, and corrective actions will be documented.
Deficiency in Emergency Preparedness Training Program
Penalty
Summary
The facility was found deficient in maintaining an emergency preparedness training program as required by regulations. During a document review on March 12, 2025, it was discovered that the facility failed to provide documentation of an emergency preparedness training program that is based on the Emergency Preparedness Plan. This program should include initial and annual training for all staff members, but the necessary documentation was not available. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed the facility's failure to develop an Emergency Preparedness Plan that includes a training program. This lack of documentation and development of a comprehensive training program indicates a significant oversight in the facility's emergency preparedness efforts.
Plan Of Correction
Facility conducted an annual in-service for staff on the emergency preparedness plan and training program. 4/28/25 Staff will be educated annually to remain in compliance. Director of maintenance will audit the emergency binder monthly x3 to ensure it is up to date.
Deficiency in Emergency Preparedness Training and Testing
Penalty
Summary
The facility was found to have a deficiency in its Emergency Preparedness (EP) program, specifically in the area of training and testing staff. During a review of the facility's EP Plan, it was discovered that the plan did not specify the type and frequency of training and testing required to ensure staff knowledge of emergency procedures. This lack of detail in the EP training and testing policy was identified during an interview and documentation review conducted on February 6, 2025. Further interviews with the Facility Administrator and Maintenance Director confirmed that the facility's EP plan was incomplete, as it did not include specific requirements for training and testing. This omission indicates that the facility failed to fully develop and maintain an EP program that meets regulatory standards, as it did not provide clear guidelines for staff training and testing to demonstrate their knowledge of emergency procedures.
Plan Of Correction
Facility trained staff on emergency procedures and tested staff on emergency procedures on March 21, 2025. Review of training and testing will be done on an annual basis by Administrator or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.
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