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)
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Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0918
Based on document review and interview, it was determined the facility failed to perform the 3-year, 4 hour building load run of the emergency generator, which serves the entire component.
Findings include:
1. Review of documentation and interview on March 27, 2025, between 8:30 AM and 11:00 AM, revealed the facility failed to have the required 3-year, 4-hour load test conducted.
Interview at the time of the exit conference with the Administrator on March 27, 2025, at 1:30 PM, confirmed the required load test was not performed.
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1. Review of documentation and interview on May 15, 2025, at 11:45 AM, revealed item 1 was not completed.
Interview at the time of the exit conference with the Administrator on May 15, 2025, at 11:50 AM, confirmed the item had not been completed.
| | Plan of Correction - To be completed: 06/05/2025
Attestation – Preparation and submission of the plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
1) Rescheduled GynServ Dynatech testing for June 4th, 2025 due to inclement weather conditions. Weather at this point looks good for scheduled service.
2) Setup a calendar reminder to get this test done every three years.
3) Educated Maintenance director and administration on K 0918 and the need to get the generator run on a 4 hour load every three years and maintain the testing in the life safety readiness book.
4) Administrator and designee will audit this every 2.75 years to ensure that it has been completed. This audit will be reviewed at QAPI.
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