Failure to Document Diesel Fuel Quality Inspection for Emergency Generator
Penalty
Summary
The facility failed to provide documentation verifying the quality of the diesel fuel servicing the emergency generator had been inspected within the previous twelve months. This deficiency was identified during a document review conducted on February 11, 2025, at 10:30 AM. The review revealed that the last documented inspection of the diesel fuel quality was dated February 8, 2023, indicating a lapse in the required annual inspection schedule. An interview with the Maintenance Manager on the same day confirmed the absence of documentation verifying the inspection of the diesel fuel quality within the past year. This lack of documentation suggests that the facility did not adhere to the necessary maintenance and testing protocols for the emergency generator's fuel supply, as required by the relevant NFPA standards.
Plan Of Correction
Contractor has been contacted to schedule testing of the emergency generator fuel. Testing frequency has been added to the electronic work order system to ensure notification of future scheduling with the contractor. Administrator and Maintenance Director shall review upcoming required tests in the electronic task work order system during monthly meeting, to ensure proper scheduling is completed in future. The Maintenance Director shall be responsible for assuring the completed testing documentation is filed in the Life Safety book for future reference. Scheduling of and completion for required contractor tests and inspections shall be reported by Director of Maintenance to QAPI committee for review/recommendation for three months. Maintenance department has been educated by Administrator on the requirement for testing the diesel fuel for the emergency generator.