Deficiency in Required Policies for Snow Removal and Fire Evacuation
Penalty
Summary
The facility was found deficient in providing required policies during a document review conducted on May 1, 2025. Specifically, the facility failed to produce policies related to snow removal and fire evacuation, which are essential for ensuring the safety and operational readiness of the facility. This deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the absence of the necessary documentation. The lack of these critical policies affects the entire facility, indicating a gap in the facility's preparedness for emergency situations.
Plan Of Correction
Facility will provide required policies, snow removal and fire evacuation affecting the entire facility. Snow removal contract was received, and the fire evacuation was completed and updated in the EP book.