Deficiency in Emergency Generator Maintenance Documentation
Penalty
Summary
The facility was found to be deficient in maintaining proper documentation for the emergency generator's annual preventative maintenance and testing for the year 2024. During a document review conducted on January 15, 2025, it was revealed that the facility could not provide the necessary documentation to confirm that the required maintenance and testing had been performed. This deficiency affects the entire facility as the emergency generator is a critical component of the essential electrical system, which is required to supply power within 10 seconds in the event of an outage. An interview with the Facilities Administrator and Assistant Maintenance Director on the same day confirmed the absence of documentation for the emergency generator's maintenance and testing. This lack of documentation indicates a failure to comply with the standards set forth by NFPA 101, NFPA 110, and NFPA 111, which require regular inspection, testing, and maintenance of emergency power systems to ensure their reliability and functionality in emergencies.
Plan Of Correction
1. Documentation for the emergency generator annual preventive maintenance was found and added to the life safety binder. 2. Review of life safety binder will be completed monthly by maintenance director/designee to ensure all needed paperwork is available. 3. Maintenance Director will bring results of monthly audit to the facility's Quality Assurance Committee for review.