Missing Generator Fuel Quality Test Documentation
Penalty
Summary
The facility failed to ensure that the required generator tests were performed in accordance with NFPA 101 and NFPA 110 standards. During a Life Safety recertification survey, it was observed that documentation for the current fuel quality tests for all three generators for the year 2024 was missing. This deficiency was identified during a documentation review of the facility's generator logs. In an interview, a Maintenance staff member confirmed that the fuel quality reports could not be located and mentioned that the vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The facilities Emergency Generator Company will complete the required annual fuel test for all three Emergency Generators. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that residents have the potential to be affected by this practice. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. The annual fuel test for the Emergency Generators was updated in the established Preventive Maintenance & Scheduling program. All inspection results will be recorded in the building Records & Logs. All maintenance staff will receive additional education and all participants will understand the life safety issues identified, with the annual fuel testing requirements for the Emergency Generators. The Director of Maintenance has been assigned the responsibility for the education of staff and report the findings to the QAPI Committee for the period of six (6) months. The facility will check for the Emergency Generator inspections and testing monthly. The Director of Maintenance will complete documentation in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted.