Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which affects the entire facility. During a document review on January 21, 2025, it was found that the facility could not provide documentation for several critical tests and inspections. These included the monthly testing of battery electrolyte specific gravity or conductance testing, an annual 90-minute load bank test, and an annual fuel quality test. An exit interview with the Executive Director of Construction and Ancillary Services confirmed the absence of the required documentation. This lack of documentation indicates that the facility did not adhere to the necessary maintenance and testing protocols for the emergency generator as outlined by NFPA standards, potentially compromising the facility's ability to provide essential power in emergencies.
Plan Of Correction
- ED of construction to Inservice supervisor of Plant Operations on ensuring generator battery testing, fuel samples and 90 min load. - Fuel test, load bank and battery conductance testing. - Director of Plants Operations or delegate to complete audits 3x per week x 4 weeks to ensure generator battery testing and fuel quality sample and 90 min load test is completed. Audit findings will be submitted to the QAPI committee monthly for further review and recommendations as needed. - Further audit frequency will be determined based on the outcome of the previously completed audit findings.