Initial Comments:
A validation survey was conducted October 21-22, 2024, to determine compliance with the requirements of the 42 CFR Part 441, Subpart D Regulations for Emergency Preparedness in Psychiatric Residential Treatment Facilities. The census during the survey was 10 and the sample consisted of six residents.
Plan of Correction:
441.184(d) STANDARD
EP Training and Testing
Name - Component - 00
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.
*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.
*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).
*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Based on review of facility provided staff training records and interview, it was determined that the facility failed to ensure that all staff were trained on the facility's emergency preparedness plan (EPP) at least every two years. This applied to two of 12 staff at the facility. Findings included:
A review of facility provided staff training records was completed on October 22, 2024. This review failed to reveal training for two staff on the facility's EPP in the past two years.
An interview was conducted with the director of residential services (DRS) on October 22, 2024, at 11:01 AM. The DRS confirmed that these two staff were not trained at least every two years on the facility's EPP.
Plan of Correction:1. The identified staff that were not trained in the facility's EPP at the time of the review will be trained on the EPP on 10/31/2024 at 9a.
2. Starting 11/1/2024 monthly training reports will be provided to the HR department and Quality Assurance will identify any staff that would need the training for EPP.
3.Corrective measures taken will include monthly training reports provided to the HR department and Quality Assurance, as well as live training reports that are accessible by the staff's supervisor. Staff will be required to take the EPP training annually according to the agencies training policy, this implementation began 11/1/2024.
4. The Quality Assurance coordinator will monitor plan effectiveness by reviewing training reports on a monthly basis and will report to the CEO and COO on success of the plan, with a goal of having the deficiency rectified by 4/15/2025.
5. The Quality Assurance Coordinator will be responsible for monitoring the corrective actions.
Initial Comments:
A validation survey was conducted October 21-22, 2024, to determine compliance with the requirements of 42 CFR Part 483, Subpart G Regulations for Psychiatric Residential Treatment Facilities. The census during the survey was 10 and the sample consisted of six residents. There were no deficiencies.
Plan of Correction:
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