|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 - Component: 01 - Tag: 0918
Based on observation and interview, it was determined the facility failed to maintain emergency generator signage, affecting the entire component.
1. Observation on May 9, 2022, at 9:35 AM, revealed the remote manual stop station, for the emergency generator, lacked identifying signage.
Interview at the time of the exit conference with the Director of Maintenance, Assistant Director of Nursing and Assistant Maintenance Director on May 9, 2022, at 1:45 PM, confirmed the lack of emergency generator stop station signage.
| ||Plan of Correction - To be completed: 06/15/2022|
Proper signage identifying the Emergency Generator Stop Station has been put in place.
The Maintenance Director or designee will review placement of signage to ensure proper identification of equipment stop station.
Review will be completed on a weekly basis for 3 weeks, then once a month for 2 months then quarterly.
Reviews will be reported to Qapi each quarter.