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 01 - Component: 01 - Tag: 0918
Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance testing for 12 of the last 12 months, effecting the entire facility.
Findings include:
1. Review of documentation on January 10, 2024, at 9:30 a.m., revealed the facility lacked documentation verifying that the following items were performed in the last twelve months:
a) 9:30 a.m., the annual preventative maintenance;
b) 9:35 a.m., the annual 90 minute load bank;
c) 9:40 a.m., an annual fuel quality test;
d) 9:45 a.m., a four hour test, required every three years.
Interview with the Facility Administrator and Maintenance Director, on January 10, 2024, at 9:30 a.m., confirmed the required annual and three year generator testing documentation was not available at the time of the survey.
** Note: during the revisit on March 6, 2024, between 8:30 a.m., and 10:30 a.m., items a,b,c, and d, were observed not to be completed.
Interview with the facility Director of Nursing on March 6, 2024, confirmed that the generator testing was not completed.
| | Plan of Correction - To be completed: 05/02/2024
918
Annual load bank test will be completed. Re-education will be provided by administrator or designee to maintenance director that facility must perform an annual load bank test of the emergency generator. An audit will be completed by the maintenance director or designee to ensure the annual load bank test of the emergency generator was completed for 2024. The results of the audit will be brought to QAPI for discussion and review.
Annual preventive maintenance will be completed. Re-education will be provided by administrator or designee to the maintenance director that facility must perform an annual preventive maintenance. An audit will be completed by the maintenance director or designee to ensure the annual preventive maintenance test of the emergency generator was completed for 2024. The results of the audit will be brought to QAPI for discussion and review.
Annual fuel quality test will be completed. Re-education will be provided by administrator or designee to maintenance director that facility must perform an annual fuel quality test of the emergency generator. An audit will be completed by the maintenance director or designee to ensure the annual fuel quality test of the emergency generator was completed for 2024. The results of the audit will be brought to QAPI for discussion and review.
A four hour test required every three years will be completed. Re-education will be provided by administrator or designee to maintenance director that facility must perform an four hour test required every three years of the emergency generator. An audit will be completed by the maintenance director or designee to ensure the four hour test of the emergency generator was completed for 2024. The results of the audit will be brought to QAPI for discussion and review.
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