Failure to Conduct Required Emergency Generator Testing
Penalty
Summary
The facility failed to ensure that all required testing and inspection were conducted on its emergency generators, as mandated by the NFPA 101 and NFPA 110 standards. During a review of the emergency generator testing and inspection records, it was found that the facility did not have a record of the three-year, four-hour load test. This test is crucial for ensuring the reliability and functionality of the emergency power supply system (EPSS) in case of a power outage. The deficiency was identified during a document review on January 7, 2025, between 12:00 pm and 1:00 pm. At the exit conference held on the same day, the facility's Administrator acknowledged the oversight and mentioned that a vendor would be contracted to conduct the required test. This indicates a lapse in the facility's compliance with the established standards for emergency power systems, which are critical for maintaining safety and operational continuity in the event of an emergency.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 I. Immediate Corrective Action The Environmental Service Director obtained a proposal from the vendor, National Standby Repair, Inc. to conduct the 3-year 4-hour load test to be conducted. II. Identification of Other Residents Once the required load test is completed, the facility respectfully states that there is no additional risk to the residents; further, there is a co-generation plant in place to provide continuous power to the facility. III. Systemic Changes The maintenance staff will receive additional education related to the life safety issues identified with inspections and testing of the Emergency Generator. Lesson Plan and attendance will be filed for validation. The 3-year, four (4) hour load test for the Emergency Generator will be added to the established Preventative Maintenance and Scheduling program, and all inspection results will be recorded in the building records and logs. The Environmental Service Director will develop an audit tool to track compliance with this requirement. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor that all inspection results for the Emergency Generator are recorded. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months, and quarterly thereafter. Any negative findings will be reported to the Administrator by the Director of Environmental Service/designee with a correction plan if warranted. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible Party: Director of Environmental Service