Lack of Documentation for Emergency Generator Maintenance
Penalty
Summary
The facility failed to maintain proper documentation for emergency generator maintenance and testing, as required by NFPA standards. During a review on February 6, 2025, it was found that the facility did not have records for several critical tests and inspections that should have been conducted within the last 12 or 36 months. Specifically, the facility lacked documentation for the annual 90-minute load bank test, the triennial four-hour load test, the annual preventative maintenance and inspection, and the annual fuel quality test. An interview with the Facility Administrator and Maintenance Director confirmed that the necessary documentation for these tests was not available at the time of the survey. This deficiency affects the entire facility, as the absence of these records indicates a failure to comply with essential maintenance and testing protocols for the emergency generator system, which is crucial for ensuring the safety and reliability of the facility's power supply in emergencies.
Plan Of Correction
Identified generator tests: 1. Annual 90-minute load bank test 2. Triennial 4-hour load bank test 3. Annual preventative maintenance and inspection 4. The annual fuel quality test will be completed by 3/21/2025. The administrator or designee will reeducate the Maintenance Director on Electrical Systems - Generator - K918. Tests will be placed on an annual/triennial schedule by the Maintenance Director or designee. Results will be reported to the Quality Assurance and Performance Improvement committee meeting.