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KOHALA HOSPITAL
EP Training Program
Tag No.: E0037
E-037 Emergency Prep
This STANDARD is not met as evidenced by:
Based on record review and staff interview, the facility failed to produce a complete Emergency Preparedness Plan (EPP) document in accordance with Appendix Z of the State Operations Manual (SOM) and 42 CFR 485.625 for Critical Assess Hospitals (CAH). Training records of annual training and testing of the EPP with staff members was not documented. This deficiency could affect all residents, staff, and visitors during an emergency due to the lack of the required training which would provide knowledge of the facility's EPP.
Findings include:
An observation on 3/22/22 at approximately 2:30 pm revealed that the facility's Emergency Preparedness Plan's Testing and Training section of the EPP did not document annual staff training to reinforce their knowledge of the respective roles and responsibilities when responding to emergencies in the facility, in accordance with Appendix Z of the SOM and 42 CFR 485.625. These findings were verified at the exit conference with the Administrator on 3/22/22 at 4:00 pm.