Deficiency in Essential Electric System Maintenance
Penalty
Summary
The facility failed to maintain its essential electric system generator in accordance with NFPA 101 standards. During a records review process conducted with the Maintenance Director, it was discovered that there was no documentation available for the performance of the fuel quality test since a report dated May 24, 2023. This lack of documentation was acknowledged by the Maintenance Director and discussed with the Administrator during the exit conference. Additionally, during a Life Safety Survey tour of the facility, it was observed that there were no generator high mortality spare parts available on the premises. This observation was made in the presence of the Maintenance Director, who acknowledged the finding. The absence of these critical spare parts was also discussed with the Administrator during the exit conference. The report highlights that the facility did not meet the requirements for maintaining the essential electric system generator as per NFPA 101. The findings were based on both the lack of documentation for fuel quality testing and the absence of necessary spare parts for the generator, which are crucial for ensuring the generator's operational readiness and compliance with safety standards.
Plan Of Correction
Identify patients that were at risk and what did: When the surveyor identified the issue we contacted the Fuel testing company and scheduled the testing. The Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. How will you identify other patients that are at risk? No other patients are a risk as the testing was completed on 4/07/2025 and results were pending. On 4/11/25 the Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. Measure put in place: When the surveyor identified the issue we contacted the Fuel testing company and scheduled the testing. The Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. How will you monitor? The Director of Plant Operations will be responsible to ensure that the Fuel test is pre-scheduled for annual requirement and that the high mortality parts are always available. Any variances will be brought to the QAPI Committee. K918 Essential Electrical Systems Identify patients that were at risk and what did: When the surveyor identified the issue we contacted the Fuel testing company and scheduled the testing. The Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. How will you identify other patients that are at risk? No other patients are a risk as the testing was completed on 4/07/2025 and results were pending. On 4/11/25 the Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. Measure put in place: When the surveyor identified the issue we contacted the Fuel testing company and scheduled the testing. The Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. How will you monitor? The Director of Plant Operations will be responsible to ensure that the Fuel test is pre-scheduled for annual requirement and that the high mortality parts are always available. Any variances will be brought to the QAPI Committee. 5/1/25