Failure to Submit Emergency Preparedness Plan for Review
Summary
The facility failed to send a copy of their Emergency Preparedness Plan (EPP) to the Camden County Office Emergency Management (CCOEM) and Local Office Emergency Management (LOEM) officials for review, as required by NJAC 8:39-31.6(h). This deficiency was identified during a review of the EPP book on December 18, 2024, at approximately 8:45 AM, which revealed no evidence of the EPP being sent to the relevant emergency management offices. During an interview, the Administrator was unable to provide evidence of the EPP being sent from January 1, 2023, through December 16, 2024. The deficiency was communicated to the Administrator and Maintenance Director during the Life Safety survey exit on December 18, 2024, at approximately 1:34 PM. This oversight had the potential to affect all 132 residents of the facility.
Plan Of Correction
1. No residents were affected by deficient practice of failing to send a copy of the facility Emergency Preparedness Plan to the County Office of Emergency Management. On 12/18/2024, an email request was sent to the County Office of Emergency Management to schedule a review of the facility's Emergency Management Plan. 2. All residents could be affected by deficient practice of failing to send a copy of the facility Emergency Preparedness Plan to the County Office of Emergency Management. 3. On 12/18/2024, a 1:1 education was completed by the Regional Plant Operations Manager with the US FOIA (b)(6) on the requirement to request an annual review of the facility's Emergency Preparedness Plan. 4. To monitor and maintain ongoing compliance, the Administrator and Regional Director of Plant Operations will review the facility's Emergency Preparedness Plan annually and ensure the Director of Maintenance requests review by the County Office of Emergency Management. The review and request to the County Office of Emergency Management will be presented to the Quality Assurance and Performance Improvement team annually to ensure compliance is maintained.
Penalty
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