Improper Medical Gas Cylinder Storage and Lapsed Emergency Management Plan
Penalty
Summary
During a fire safety tour, surveyors observed that the facility failed to properly store medical gas cylinders in accordance with NFPA 99 standards. Specifically, in the outdoor oxygen storage area, which was detached from the main building by approximately twenty-five feet, six flammable liquid cans were found stored directly next to full oxygen cylinders. Among these cans, two contained a mixture of gasoline and oil, while the remaining four were empty. The oxygen storage area contained twenty-three full E-cylinders and one full H-cylinder. The presence of flammable liquids in close proximity to oxidizing gases is a direct violation of the required separation and storage protocols outlined in NFPA 99. Additionally, the facility was unable to produce a current, approved Comprehensive Emergency Management Plan (CEMP) during the record review. The last approved CEMP was dated over a year prior, and subsequent submissions had either expired or been rejected. The most recent resubmission was still pending approval at the time of the survey. This failure to maintain an up-to-date and approved emergency management plan is not in compliance with Florida Administrative Code requirements, which mandate annual review and approval of such plans. Both deficiencies were acknowledged by facility leadership, including the Maintenance Director and the Administrator, during interviews conducted at the time of the survey. The findings were reviewed with the relevant facility staff at the exit conference. Photographic evidence was obtained to document the improper storage of medical gas cylinders and the presence of flammable liquids in the oxygen storage area.
Plan Of Correction
Immediate Corrective Action The six flammable liquid cans were removed from the outdoor oxygen storage area on 5/27/2025, during the survey. Method to Assess Others The facility only has one oxygen storage area so no further evaluation was needed. Systematic Process The Maintenance Director, or designee, will perform weekly inspections X 8 weeks of the outside oxygen storage area to ensure there are no flammable liquids stored in the area. Quality Assurance The Administrator, or designee, is responsible for the oversight of this program. Documentation of the outdoor oxygen storage area inspections will be brought to the monthly QAPI meeting for review X 2 months. If substantial compliance is not met after 2 months, weekly inspections will continue and be brought to the monthly QAPI meeting until substantial compliance is met. --- Immediate Corrective Action The Administrator reached out to the Palm Beach County Division of Emergency Management on 4/30/2025 for an update and was given a timeframe of 60 days until the CEMP would be reviewed and then approved. Method to Assess Others No other disaster preparedness documentation was identified for submission to the Palm Beach County Division of Emergency Management. Systematic Process The Administrator, or designee, will continue to ensure the facility's CEMP is submitted to the Palm Beach County Division of Emergency Management within 60 days of the previous year's approval date. Quality Assurance The Administrator is responsible for the oversight of this process. QAPI will be notified when the CEMP is submitted for annual approval until substantial compliance is made. --- Immediate Corrective Action The six flammable liquid cans were removed from the outdoor oxygen storage area on 5/27/2025, during the survey. Method to Assess Others The facility only has one oxygen storage area so no further evaluation was needed. Systematic Process The Maintenance Director, or designee, will perform weekly inspections X 8 weeks of the outside oxygen storage area to ensure there are no flammable liquids stored in the area. Quality Assurance The Administrator, or designee, is responsible for the oversight of this program. Documentation of the outdoor oxygen storage area inspections will be brought to the monthly QAPI meeting for review X 2 months. If substantial compliance is not met after 2 months, weekly inspections will continue and be brought to the monthly QAPI meeting until substantial compliance is met.