Deficiency in Emergency Generator Fuel and Power Maintenance Planning
Penalty
Summary
The facility failed to ensure that its emergency preparedness policy included a plan for maintaining generator power and fuel during an emergency. During a record review, it was found that the Emergency Preparedness Policy did not reference any procedures or strategies for keeping the emergency power systems operational in the event of a power outage or other emergency situations. This omission was specifically noted in the documentation provided by the facility. At the time of the survey, an interview with facility staff confirmed that there was no plan in place to maintain fuel sources for the emergency generator during an emergency. Additionally, there was no documented plan for supplying power to the building if the generator failed to operate during such an event. This lack of planning was acknowledged by the staff member interviewed by the surveyor. The deficiency was communicated to the facility's leadership during the Life Safety Code exit conference. The absence of a comprehensive emergency power and fuel maintenance plan was identified as a failure to meet the requirements set forth by federal regulations and referenced standards, including NFPA 99 and NFPA 110.
Plan Of Correction
Element #1 On 6/6/2025 the Administrator and the Maintenance Director went to do an audit on the facility contract and reports with our vendor Powerhouse, which services our generator. In the binder of contracts, we found the contract dated 1/1/2025, stating clearly that Powerhouse will service our facility with fuel throughout the time the generator is on during an emergency and will replace it with a rental if the current generator malfunctions (see policy attached). Element #2 All residents have the potential to be affected by this deficient practice when life safety reports and contracts are not handy and not in the right binder. Element #3 The administrator in-serviced the US FOIA (b)(6) the same day 6/6/25 about the importance of having all reports and contracts related to lift safety, to be stored in the emergency preparedness binder and to check monthly contract and report from the Vendor Powerhouse who services the generator, that they are up to date with life safety compliance. In addition, the administrator in-serviced the maintenance director on the responsibility of having a contracted vendor service the generator throughout the emergency and having a backup generator in case it malfunctions. Element #4 The Administrator will monitor the Maintenance Director for three (3) months starting 6/9/2025-9/9/2025 weekly on having all life safety reports and contracts handy and placed in the Emergency preparedness binder for all life safety compliance. All findings will be reviewed and discussed in the next Quarterly QAPI committee meeting.