Failure to Conduct Triennial Generator Testing
Penalty
Summary
The facility failed to conduct the required triennial testing of its emergency generator, as evidenced by a review of maintenance and testing records. The last recorded triennial load test was dated September 30, 2021, indicating that the facility did not perform the necessary testing within the stipulated three-year period. This oversight was identified during a record review on April 1, 2025, at 10:30 a.m. The Maintenance Director acknowledged the absence of current triennial load testing records during the review. This deficiency could potentially lead to a malfunction of the generator in the event of a power failure, resulting in a loss of power to the entire facility. The facility's failure to adhere to the NFPA 110 standards for generator maintenance and testing poses a risk to the safety and operational integrity of the facility.
Plan Of Correction
1. **Corrective Action for Cited Instance:** The facility immediately scheduled the required 4-hour triennial load test, which was conducted and completed on May 2nd, 2025, and followed with an amendment signed 04-09-2025 to the current contract for a 4-hour load bank every three years and two-hour load bank to comply ordinance by a licensed contractor in accordance with NFPA 110 Section 8.4.2. 2. **Systemic Correction:** A compliance calendar has been implemented to track future due dates for generator testing, inspections, and maintenance. 3. **Education:** The Maintenance Director received updated training on generator testing frequency requirements per NFPA 110 and NFPA 111 on April 7, 2025. 4. **Ongoing Monitoring:** All generator test logs, and vendor documentation will be reviewed quarterly led by the Director of Maintenance or designee. 5. **Quality Assurance:** Generator compliance will be tracked and reported to the QA Committee monthly starting April 2025 to ensure continued adherence and oversight. **Completion Date:** April 27, 2025