Failure to Document Emergency Preparedness Collaboration
Summary
The facility failed to develop and maintain an emergency preparedness plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. Specifically, the plan did not contain documentation of the facility's efforts to contact these officials or evidence of participation in collaborative and cooperative planning efforts. This deficiency was identified through document review and interviews conducted on June 30, 2025. During the exit interview with the Maintenance Supervisor and Director of Safety/Security, it was confirmed that the required documentation was not available. The lack of a documented process and evidence of communication or collaboration with emergency preparedness officials affected the entire facility.
Plan Of Correction
Policy in place and will ensure that policy is present in emergency preparedness binder for future surveys. E 0009
Penalty
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