Deficiencies in Electrical System Maintenance and Outlet Monitoring
Penalty
Summary
The facility was found to have deficiencies related to the maintenance and testing of its electrical systems, specifically concerning the essential electric system (EES) and the use of outlet multipliers. During an interview with the Director of Maintenance, it was confirmed that a corridor door did not positively latch, which is a requirement under the National Fire Protection Association (NFPA) 101 standards. Additionally, the facility failed to meet the NFPA 101 requirements for monitoring the use of outlet multipliers, as evidenced by the observation of a receptacle multiplier being used in the basement laundry area by the dryers. The report highlights that the generator and associated equipment must be capable of supplying service within 10 seconds, and if this criterion is not met during monthly tests, an annual confirmation process is required. The facility is also required to maintain written records of maintenance and testing, ensure EES electrical panels and circuits are marked and separate from normal power circuits, and minimize the possibility of damage to the emergency power source. However, the facility's failure to monitor the use of outlet multipliers in one of the smoke compartments indicates a lapse in adhering to these standards, as confirmed by the Director of Maintenance.
Plan Of Correction
1. Multiplier was removed and existing receptacle is now being utilized. 2. Facility has completed an audit to ensure no other multipliers are being used. 3. Maintenance director/designee will conduct monthly inspections to ensure no multipliers are being utilized. Audits will be reviewed at QAPI to ensure compliance.