Failure to Document Emergency Generator Maintenance and Testing
Penalty
Summary
The facility failed to perform all required emergency generator maintenance and testing over the past 12 months, as evidenced by a lack of documentation for several critical tests and maintenance activities. During a documentation review on January 29, 2025, it was found that the facility did not have records verifying the completion of the annual 90-minute load bank test, the triennial four-hour test, the annual preventive maintenance, and the annual fuel quality test. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director, who acknowledged that the necessary documentation was not available at the time of the survey. The absence of these records indicates that the facility did not adhere to the required maintenance and testing protocols for its emergency generator systems, as outlined by NFPA standards. This failure affects the entire facility, as the generator is a critical component of the essential electrical system, ensuring power supply during emergencies. The lack of documentation suggests that the facility may not have conducted these essential tests and maintenance activities, which are crucial for the reliable operation of the emergency power system.
Plan Of Correction
The 90 minute load bank test, triennial four-hour test, annual preventative maintenance, and the annual fuel quality test will be completed by 2/12/25. This will be audited annually for completion. Results will be reported to the quality assurance and performance committee. The 90 minute load bank test, triennial four-hour test, annual preventative maintenance, and the annual fuel quality test will be completed by 2/12/25. This will be audited annually thereafter to ensure completion. Results will be reported to the quality assurance and performance committee.