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 document review and interview, it was determined the facility failed to maintain the emergency generators, affecting two of twelve monthly inspections.
Findings include:
1. Document review on May 12, 2022, at 9:45 am, revealed the facility lacked documentation showing the following required emergency generator maintenance items had been conducted: a. monthly load test since February 18, 2022. b. monthly transfer switch operation since February 18, 2022, due to faulty transfer switch.
Interview at the exit conference with the Maintenance Director and the Director of Nursing on May 12, 2022, at 12:30 pm, confirmed the missing documentation.
| | Plan of Correction - To be completed: 06/20/2022
Monthly load test was performed May 13, 2022. ATS was replaced on May 12, 2022. Monthly load testing remains in the system as part of the Preventive Maintenance schedule. The Maintenance Dept employees will be in-serviced on proper documentation and testing with this required monthly task.
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