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: CLASS C ASC - Component: 10 - Tag: 0918
Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.
Findings include:
Document review on August 27, 2024, between 9:00 a.m. and 11:00 a.m, revealed:
a) The facility could not produce documentation of an annual, 90 minute load bank test.
b) The facility could not produce documentation of an annual, fuel quality test.
Exit Interview with the Administrator on August 27, 2024, at 11:30 a.m., confirmed the lack of documentation.
| | Plan of Correction - To be completed: 08/27/2024
S 0918 Electrical Systems -Essential Electric System
GENERATOR LOAD BANK TEST /FUEL ANALYSIS
SYSTEMIC CHANGES:
LOAD BANK TEST
The CD reviewed the December 2023 annual PM with Generator Vendor and verified the annual 90-minute load bank test was completed on 12/22/2023, a copy of the report was obtained on 8/27/2024. The next annual PM is scheduled to take place in December 2024. The CD will obtain the report and file it in EOC binder once it is reviewed. The CD will ensure the Generator PM is scheduled per requirements.
MONITORING AND SUSTAINING THE PLAN:
The CD will confirm PM report has been received and any actionable findings if applicable, are reported to the Governing Body. The CD or designee will schedule the generator PM per requirements including 90-minute load bank testing, and reports will be reviewed and then stored in the Environment of Care binder. Once the report is reviewed, the PM/Testing date will be documented on the EOC checklist and CD will monitor this for 100% compliance.
RESPONSIBLE PARTY AND REPORTING:
The CD is responsible to implement the changes identified in this PoC. The CD will provide results of this survey, the corrective .actions, and results from monitoring to the QAPI Committee quarterly for review and recommendations. Recommendations will be submitted to the Governing Body for review and approval.
FUEL ANALYSIS:
The CD contacted the facility's Generator Vendor on 8/27/2024, the Generator fuel analysis is scheduled to be completed on 09/13/2024. Once the sample is obtained the CA will follow up with the vendor on 9/27/24 for report status if not yet received, and then weekly after that until the Fuel Sample analysis report is obtained. The CD will review the report when received for any further action. The CD verified the annual Fuel analysis is included in the Generator Vendor contract.
MONITORING AND SUSTAINING THE PLAN:
FUEL ANALYSIS
The CD will confirm the report has been received and any actionable findings if applicable, are reported to the Governing Body. The CD or designee will schedule the generator fuel analysis on an annual basis and reports will be reviewed and then stored in the Environment of Care binder. Once the report is reviewed, the Testing date will be documented on the EOC checklist and CD will monitor this for 100% compliance.
RESPONSIBLE PARTY AND REPORTING:
The CD is responsible to implement the changes identified in this PoC.
The CD will provide results of this survey, the corrective actions, and results from monitoring to the QAPI Committee quarterly for review and recommendations. Recommendations will be submitted to the Governing Body for review and approval.
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