Failure to Maintain Essential Electrical System
Penalty
Summary
The facility failed to maintain and test their Essential Electrical System in accordance with NFPA 99 standards. During a record review conducted on February 4, 2025, it was identified that there was no documentation available for weekly voltage checks for two generator batteries. Additionally, there was no documentation for monthly sealed battery conductance tests for these same batteries. This lack of documentation indicates that the facility did not perform the required maintenance and testing procedures for their generator batteries. The Regional Director of Maintenance was present during the record review and acknowledged the findings. The absence of these critical maintenance records suggests a failure to adhere to the necessary protocols for ensuring the reliability and safety of the facility's emergency power systems. This deficiency was noted as a violation of the NFPA 99 and NFPA 110 standards, which are essential for maintaining the operational readiness of the facility's electrical systems.
Plan Of Correction
Corrective Actions The following actions occurred on 2/17/2025: A. The weekly generator inspection form was updated to include a battery voltage reading for both generator batteries. B. The monthly generator inspection form was updated to include a battery conductance reading for both generator batteries. Identification of Others Potentially Affected Both facility generator batteries were accounted for, so no further evaluation was needed. Systemic Changes The Maintenance Director, or designee, will continue to perform documented weekly generator inspections to include documentation of the battery voltage, and monthly generator testing to include documentation of the battery conductance testing, on an ongoing basis as part of the facility's life safety program. Quality Assurance Results of the weekly inspections and monthly battery testing will be presented at the monthly QA meetings for 3 months. If substantial compliance is not met after 3 months, monthly inspections will continue, and results will be brought to QA meetings until substantial compliance is met.