Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies, in 2 of 4 personnel records reviewed.
The findings include:
Two records requiring documentation that personnel on all shifts were trained to perform assigned tasks during emergencies, were reviewed on January 21, 2016.
Employee # 2 was hired on May 26, 2015. The training for assigned tasks during emergencies was not documented as of the date of the inspection.
Employee # 4 was hired on December 4, 2015. The training for assigned tasks during emergencies was not documented as of the date of the inspection.
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Plan of Correction
Upon hire all individuals will be trained on NHS fire evacuation policy and site specific evacuation procedures. This outlines roles and responsibilities of staff during emergencies. Staff will sign acknowledgement form that training was completed. Acknowledgement will be kept in personnel file. Additionally, emergency procedure training will be added to individual training tracking form for management tracking mechanism.
This will be completed immediately for those cited. Ongoing for new hires.
Project director will be responsible for implementation and tracking. |