Deficient Emergency Preparedness Policy for Natural Gas Interruption
Penalty
Summary
The facility failed to develop and implement emergency preparedness policies and procedures specifically addressing the loss of natural gas to the building. During a record review, it was found that there were no established policies outlining how the facility would maintain operations in the event of an interruption to the natural gas supply. This omission was identified as a deficiency in the facility's emergency preparedness planning. The deficiency was confirmed during an interview with the Maintenance Director at the time of the record review. The lack of a policy for natural gas interruption means the facility did not meet the requirement to review and update emergency preparedness policies and procedures at least annually, as mandated. This finding could potentially affect all occupants in the event of an emergency involving the loss of natural gas.
Plan Of Correction
Element 1: Policy for Natural Gas Outage created on 06/04/2025. Element 2: All residents have the potential to be impacted by this deficiency. Best practice is to have a policy surrounding natural gas outage. Element 3: Physical plant manager and Administrator created policy and staff were educated on 06/05/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance.