Failure to Maintain Generator Fuel Quality Testing and Annual Emergency Management Plan Submission
Penalty
Summary
The facility failed to maintain the required annual diesel fuel quality test for its generator, as mandated by NFPA 101, NFPA 99, and NFPA 110. During a record review of the Essential Electrical System (EES) with the Director of Maintenance (DOM), it was found that there was no evidence of a current annual diesel fuel quality test. The DOM confirmed during the interview that the documentation for this test was not available. Additionally, the facility did not submit its comprehensive emergency management plan (CEMP) for annual review and approval as required by Florida Administrative Code 408.821. During a record review with the DOM, it was revealed that the facility could not provide evidence of the CEMP's submission to the county for the required annual review. The CEMP had expired, and the DOM stated that the facility currently has an interim Administrator who has only been at the facility for a few months. No information was provided in the report regarding specific residents or their medical conditions in relation to these deficiencies. The findings were based on documentation review and interviews with facility staff, specifically the DOM.
Plan Of Correction
Fuel sample was collected on by vendor for testing. No residents were affected by deficient practice. Education will be completed with the NHA/designee by regional plant operations on fuel inspection requirements. Audits will be completed by the NHA/designee who will audit the electronic work order system for equipment inspection compliance weekly for four weeks then monthly for two months. Results of the audit will be reported to the QAA&C Committee for comments and recommendations monthly for three months. CEMP was submitted to the county agency for review. No residents were affected by deficient practice. Education was completed with the NHA/designee by the regional director of plant operations regarding the annual requirement for CEMP approval. Audits will be completed by the NHA/designee on the CEMP approval compliance weekly for four weeks then monthly for two months. Results of the audit will be reported to the QAA&C Committee for comments and recommendations monthly for three months.