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 and inspect the emergency generator, affecting five of twelve reports.
Findings include:
Document review on December 18, 2023, at 8:45 a.m., revealed the facility could not provide documentation of the following tests:
a. Monthly testing of battery conductance after July of 2023; b. 3 year, 4 hour load test.
Exit interview with the Administrator and the Maintenance Director on December 18, 2023, at 12:00 p.m., confirmed the lack of documentation.
| | Plan of Correction - To be completed: 02/16/2024
A. 1. The Maintenance Director/designee will perform monthly conductance battery testing and will attach receipts to monthly generator reports. 2.The Maintenance Director will monitor monthly battery testing audits. 3. The corrective action will be reported in QAPI monthly x6. 4. Corrective action will be in place by 2/16/2024 B 1.Facility has had it's 4-hour Load test completed. 2. Facility will maintain the 3- year, 4-hour load test report in facility & will add to TELS maintenance system to alert Maintenance Director/designee. 3. The corrective action will be monitored through the TELS system alerting Maintenance Director of due inspection. 4. Upcoming monthly maintenance inspections will be reported in QAPI for 3-months. 5.Corrective action will be in place by 2/16/2024.
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