Lack of Emergency Generator Fuel Supply Agreement
Penalty
Summary
The facility failed to maintain its Emergency Preparedness Plan as required by federal regulations. During a document review and staff interview, surveyors requested the emergency fuel plan and found that the facility could not provide a written vendor agreement for the delivery of fuel for their 10-kilowatt propane generator in the event of an emergency. Staff confirmed that while a fuel contract had been proposed to the vendor, no agreement had been finalized or received at the time of the survey. This deficiency affected all 123 residents and four smoke compartments within the facility. The absence of a documented fuel supply agreement meant that the facility did not have a formalized plan to ensure the continued operation of its emergency power system during an emergency, as required by the applicable federal regulations and referenced NFPA codes.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by this provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. The plan of correction is prepared and executed solely because it is required by the provisions of federal and state law. I. Corrective Action The facility will ensure to maintain the Emergency Preparedness Plan. On 04/02/25, the Administrator requested a written agreement with [R] to deliver propane fuel for the generator in the event of an emergency. On 04/18/25, [R] provided an amended service agreement that includes a 24-hour emergency service for our facility. (Attachment A - page 6) II. Identify Other Residents at Risk No residents were affected by this deficient practice. III. Systematic Changes On 04/03/25 in-service was conducted by the DSD to facility staff to be informed of agreement in place between propane fuel supplier and facility to deliver propane fuel for generator in the event of an emergency (Attachment 1). EOP Manual updated and reviewed by QA Committee. Next review of EOP Manual will be on 03/2026. IV. Monitoring Process Maintenance Director will review monthly EOP Manual including Propane Fuel Delivery Agreement. Findings will be reported to Administrator in the daily operations meeting. The Administrator will report findings to QA Committee monthly for 3 months or until compliance is met. V. Completion Date 04/18/2025 E 041 The facility is not in substantial compliance with 42 CFR §483.90 for Long Term Care Facilities.