Failure to Maintain and Test Generator System
Penalty
Summary
The facility failed to maintain and test its generator system in accordance with the required standards, affecting the entire facility. During a document review, it was found that the facility could not provide documentation for specific tests over the past twelve months. These missing documents included a natural gas reliability letter and records of monthly testing of battery specific gravity or battery conductance. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director. The lack of documentation indicates that the facility did not adhere to the necessary maintenance and testing protocols for its essential electrical systems, as outlined by NFPA standards. This oversight could potentially impact the facility's ability to ensure a reliable power supply in emergency situations.
Plan Of Correction
Maintenance Director has contacted the facility's natural gas company to obtain a copy of the Natural Gas Reliability Letter. Maintenance Director and/or designee initiated monthly testing of battery specific gravity or battery conductance to ensure the generator is properly maintained. Maintenance Director will present the Natural Gas Reliability Letter and monthly testing of the generator battery to Quality Council for review to ensure compliance.