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 01 - Component: 01 - Tag: 0918
Based on document review, observation and interview, it was determined the facility failed to provide required maintenance and testing documentation for the emergency generator, affecting the entire facility.
Findings include:
1. Review of documentation on October 23, 2025, revealed the facility lacked documentation for the required emergency electrical system inspections and testing for the following:
a) 10:25 a.m., weekly Visual inspections (from July 2025 to October 2025);
b) 10:30 a.m., weekly Battery Electrolyte Levels or Battery Voltage Levels (from July 2025 to October 2025);
c) 10:35 a.m., monthly Battery Electrolyte Specific Gravity Testing or Conductance Testing (from July 2025 to October 2025);
d) 10:40 a.m., monthly (20-40 days) 30 minute load test (from July 2025 to
October 2025;
e) 10:45 a.m., monthly operation of the Automatic Transfer Switch (from July 2025 to October 2025).
Interview with the Facility Administrator on October 23, 2025, at 11:00 a.m., confirmed the facility was unable to provide documentation of the required emergency electrical system inspections and tests.
| | Plan of Correction - To be completed: 12/12/2025
The Administrator will educate the Maintenance Director regarding the requirements of maintaining and documenting a preventative maintenance program for the emergency generator. The preventative maintenance program will include: 1) Weekly visual inspection of the generator, 2) Weekly inspection of battery levels or electrolyte levels, 3) Monthly Battery Electrolyte specific gravity testing, 4) a monthly 30-minute load test, 5) Monthly operation of the automatic transfer switch.
A calendar will be developed and implemented providing guidance to the Maintenance Director in reference to completing and documenting the monthly preventative maintenance checks on the generator during the 2nd week of every month and weekly for weekly preventative maintenance. The preventative maintenance will include: 1) Weekly visual inspection of the generator, 2) Weekly inspection of battery levels or electrolyte levels, 3) Monthly Battery Electrolyte specific gravity testing, 4) a monthly 30-minute load test, 5) Monthly operation of the automatic transfer switch.
In order to ensure the deficient practice does not recur, the calendar will be shared jointly between the Maintenance Director and Administrator, and the inspections and testing will be documented by the Maintenance Director and emailed to the Administrator on a weekly basis once the preventative maintenance has been completed.
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