|Electrical Systems - Essential Electric System Maintenance and Testing|
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918
Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance and testing for five of 12 months.
1. Document review on September 24, 2019, at 10:10 a.m., revealed the emergency generator had not been exercised under a 30 minute load for the months of April, May, June, July and August, 2019, document review also revealed the emergency generator did not have weekly maintenance from March 21, 2019 until August 17, 2019 equaling 23 weeks.
Interview with the Facility Director and Maintenance Staff, on September 24, 2019, at 12:30 p.m., confirmed the required weekly and monthly generator maintenance and testing was not being performed.
| ||Plan of Correction - To be completed: 11/05/2019|
1. Actions taken for the situation identified:
The facility has developed a weekly and monthly generator form. Weekly/monthly testing began in September.
2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected and will ensure that the weekly and monthly generator tests are conducted, as required.
3. System changes and measures to be taken:
The Administrator or designee will review the Life Safety requirements related to the Essential Electrical Equipment with the Director of Maintenance and the Quality Assurance Performance Improvement Committee.
4. Monitoring mechanisms to assure compliance:
The Administrator will ensure that the weekly and monthly generator testing is conducted as required. A tracking system will be developed to log annual reviews, audits, and inspections, including the weekly and monthly testing, and the Administrator will monitor compliance of this tracking system. Monitoring reports will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings and further action plans and audits will continue until substantial compliance is achieved. From then on, monthly Quality Assurance Performance Improvement meetings will help to ensure quality standards are met through continual performance analyses and the implementation of systematic efforts to improve those processes that do not meet acceptable levels. This will include self-monitoring of identified deficient practices that shall be reviewed during the monthly Quality Assurance Performance Improvement Committee meetings, as well as the Quarterly Quality Assurance Meetings, until significant corrections are noted and ongoing, as necessary.
5. Date Corrective Action will be completed:
Substantial compliance is expected by 11/5/19.