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 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: MAIN BUILDING - Component: 01 - Tag: 0918
Based on document review and interview, it was determined the facility failed to provide documentation verifying weekly and monthly inspections of the emergency generator, affecting the entire component.
Findings include:
1. Review of documentation on February 21, 2024, at 9:00 AM, revealed the facility failed to provide documentation verifying weekly visual inspections of the emergency generator were performed prior to 5/5/23.
Interview with the Administrator on February 21, 2024, at 9:00 AM, confirmed the facility did not provide documentation verifying weekly visual inspections of the emergency generator were performed for the previous 12 months.
2. Review of documentation on February 21, 2024, at 9:10 AM, revealed the facility failed to provide documentation verifying monthly exercises of the emergency generator were performed prior to 6/22/23.
Interview with the Administrator on February 21, 2024, at 9:10 AM, confirmed the facility did not provide documentation verifying monthly exercises of the emergency generator were performed for the previous 12 months.
| | Plan of Correction - To be completed: 04/02/2024
Moving forward, weekly documented visual inspections of the emergency generator will take place and monthly documented exercises of the emergency generator will be performed.
The weekly visual inspection documentation and monthly generator exercise documentation will be maintained in the Life Safety Book by the Director of Facilities/designee.
Compliance with the visual inspection and exercise of the emergency generator will be reported quarterly to the QAPI Committee by the Director of Facilities/designee for further review and recommendation.
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