Emergency Generator Maintenance Deficiencies
Penalty
Summary
The facility's emergency generator was found to be inadequately maintained during a Life Safety Code survey. The survey revealed that there was no documentation of annual diesel fuel quality testing for the years 2023 and 2024, with the last recorded test being in March 2022. The Director of Facilities Maintenance/Corporate was unable to provide documentation for these years and stated that the outside contractor responsible for maintenance typically handled fuel testing and documentation. Additionally, there were gaps in the generator's monthly load test records, with missing documentation for specific periods in 2024. The computerized maintenance system showed incomplete records for these tests, lacking essential details such as hour meter information. Furthermore, the survey identified that the emergency manual stop station for the generator was not located in a remote area, as required. The only stop station was found on the generator itself, and staff, including the Administrator and Director of Facilities Maintenance/Corporate, were unaware of any remotely located stop station. This lack of awareness extended to the Maintenance Assistant, who had been conducting load tests due to a vacancy in the Director of Maintenance position. The absence of a remote stop station and the lack of knowledge among key staff members about its location were significant findings in the survey.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 Corrective action for the areas found to be deficient were to obtain fuel samples on an annual basis, conduct monthly generator load tests, and add a remote emergency stop to the generator. Outside Contractor provided documentation for 2024; however, results for 2023 were not found. The remote emergency stop will be installed by outside contractors. Audits will be conducted by the Maintenance Director consisting of a monthly load test on the generator, which includes the fuel and oil checks as well as the remote emergency stop button for proper functioning. A weekly no load test will be conducted. Education will be provided to the Director of Maintenance to maintain compliance with generator regulations. The monthly testing will be recorded in the TELS system. The results of the audits will be reported to the QA committee on a monthly basis. The Administrator will provide education to the Maintenance Director. Reviewed monthly in QA for 3 months. Responsible - Maintenance Director will train the maintenance team. Maintenance Director will implement the P(NAME).