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 four 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 and readily identifiable. 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 01 CLASS C ASF - Component: 01 - Tag: 0918
Based on document review and interview, it was determined the facility failed to maintain and inspect components of the emergency generator, affecting the entire facility.
Findings include:
1. Document review on July 26, 2023, at 8:15 am, revealed the facility could not produce documentation of monthly testing of battery electrolyte specific gravity or battery conductance.
Exit interview with the Administrator on July 26, 2023, at 10:15 am, confirmed the lack of documentation.
| | Plan of Correction - To be completed: 08/03/2023
The emergency generator lacked monthly conductance testing of sealed battery, which was installed on June 7, 2023. The Generator Power Company contacted on July 26, 2023 to request device to test conductivity. Unit was ordered and received on July 27, 2023. The generator conductance test was performed and completed on July 28, 2023 at 14:44:04 and report indicated "Good & Pass." Testing will be completed monthly and report added to inspection checklist to ensure compliance. Report available upon inspection. Results will be reported to the Patient Safety Committee August 2023 meeting. Medical Advisory Board and Governing Board August 2023.
The Administrator and Medical Director are responsible for this plan of correction.
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