Generator Testing Deficiency
Summary
The facility failed to ensure that the emergency generator was inspected and tested in accordance with the NFPA 99 Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems. Specifically, there was no evidence that the generator was capable of supplying service within the required 10-second interval after a loss of normal power. This deficiency was identified during a document review and staff interviews, where it was noted that the monthly full load test logs did not include the transfer time, making it impossible to verify compliance with the 10-second requirement. During the survey, the Director of Building Services acknowledged the omission and stated that the transfer time would be added to the monthly load test moving forward. Additionally, maintenance staff, who had been working at the facility for several years, confirmed that they had never been asked to record the transfer time, although they believed the generator started within 5 seconds. This oversight in documentation and testing procedures led to the deficiency being cited.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. Generator log sheets were immediately updated to include transfer times for each test. II. Anyone has the potential to be affected. III. The maintenance department was educated on NFPA 101 Electrical System Maintenance and testing by Director of Maintenance on 2/12/25. IV. Audit tool was created to ensure generator logs included transfer time sections going forward. Audits will be conducted by the director of maintenance monthly for 12 months. V. Responsible party: Director of Maintenance/ Designee
Penalty
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