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: (CLOSED) CLASS C ASF - Component: 01 - Tag: 0918
Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility.
Findings include:
1. Document review on August 2, 2023, at 11:50 am, revealed the facility could not produce documentation showing that a 3-year 4-hour exercise of the generator had been performed.
Exit interview with the Administrator on August 2, 2023, at 1:15 pm, confirmed the missing documentation.
| | Plan of Correction - To be completed: 08/17/2023
Observations #: 0918
Modern Power Group in Bristol Pennsylvania maintains and maintenance the generator for Cornerstone Ambulatory Surgery Center. On August 17,2023 Modern Power will perform the 3-year 4-hour exercise of the generator and provide written documentation.
In accordance with NFPA 101 STANDARD Electrical Systems - Essential Electric System; 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 includes 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). The CASC has included the 3-year 4-hour exercise of the generator within their contract on an annual basis.
The DON will be responsible for monitoring ongoing compliance. This will be discussed at our next staff meeting and will continue to be checked on our preventative Maintenance Checklist and Life Safety checklist.
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