Failure to Train Staff on Emergency Preparedness
Summary
The facility failed to provide training on Emergency Preparedness for one of its staff members, identified as Employee E12. According to the facility's "Facility Assessment" dated January 26, 2025, new staff are required to receive training during orientation, and existing staff are to be trained monthly on specific topics to meet educational requirements. However, a review of the facility's documents and training records revealed that Employee E12, who was hired on July 1, 2023, did not receive documented in-service education on Emergency Preparedness between July 1, 2023, and July 1, 2024. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 14, 2025.
Plan Of Correction
Nurse aide employees will be trained on emergency preparedness by 4.14.2025. To prevent this from recurring, the NHA/designee educated Human Resources on regulatory requirements of F1570. To monitor and maintain ongoing compliance, the DON/designee will audit employee records for Emergency Preparedness weekly x4, then monthly x2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Penalty
The facility did not provide annual Emergency Preparedness training to six staff members, including several nurse aides and an LPN, as required by facility policy. Personnel files lacked documentation of this training within the required timeframe, and this was confirmed by Human Resources during the survey.
The facility failed to provide emergency preparedness training for two nurse aides, as required by their policy. Employee E11 and Employee E15 did not receive the necessary training within the specified timeframes. The Nursing Home Administrator confirmed this deficiency during an interview.
The facility failed to ensure that four nurse aide employees completed the required annual emergency preparedness education. A review of records and staff interviews revealed that these employees did not have documented training on emergency preparedness within the specified time frames. The Nursing Home Administrator confirmed this deficiency.
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.
Failure to Provide Emergency Preparedness Training
Penalty
Summary
The facility failed to provide required training on emergency preparedness for two nurse aides, identified as Employee E11 and Employee E15. According to the facility's policy titled 'In-Service Training, All Staff,' which was most recently reviewed on March 14, 2025, all personnel are required to receive education and training related to resident care, including emergency preparedness. However, a review of the facility's documents and training records revealed that Employee E11, hired on March 26, 2023, did not receive emergency preparedness training between March 26, 2024, and March 26, 2025. Similarly, Employee E15, hired on April 14, 2014, did not receive the required training between April 14, 2024, and April 14, 2025. During an interview conducted on April 18, 2025, the Nursing Home Administrator confirmed the facility's failure to provide the necessary emergency preparedness training for these two nurse aides. This deficiency was identified based on the review of facility policy, personnel in-service training records, and staff interviews.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Emergency Preparedness on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed training platform and discovered that 1570 was not uploaded to the training platform. Emergency Preparedness has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 1570 training courses completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Failure to Complete Annual Emergency Preparedness Training
Penalty
Summary
The facility failed to ensure that employees completed the required annual emergency preparedness education for four nurse aide employees. A review of employee education records and staff interviews revealed that Nurse Aide Employees E6, E7, E8, and E9 did not have documented training on emergency preparedness. Specifically, NA Employee E6, hired on 9/16/21, did not complete the required training between 9/16/23 and 9/16/24. NA Employee E7, hired on 10/4/12, failed to complete the training between 10/4/23 and 10/4/24. NA Employee E8, hired on 10/14/13, did not have the training documented between 10/14/23 and 10/14/24. Lastly, NA Employee E9, hired on 8/15/22, did not complete the training between 8/15/24 and 8/15/24. The Nursing Home Administrator confirmed the facility's failure to ensure the completion of the required annual emergency preparedness education for these employees during an interview on 1/24/25.
Plan Of Correction
1. The facility will ensure employees receive Emergency Preparedness on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each employee to ensure ongoing yearly training. 3. The Maintenance Manager and Human Resources Director or designee will ensure that each employee of the facility receives Emergency Preparedness training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.
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