Failure to Conduct Required 4-Hour Load Test for Essential Electrical System
Penalty
Summary
The facility failed to comply with the National Fire Protection Association (NFPA) standards for maintaining and testing their Essential Electrical System (EES). Specifically, the facility did not conduct the required tri-annual 4-hour load test for their generator and associated equipment. This test is crucial to ensure that the generator can supply power within 10 seconds in case of an emergency, as stipulated by NFPA 110 and NFPA 111 guidelines. During a document review and interview conducted on April 22, 2025, it was discovered that the last documented 4-hour load test was performed in December 2021. This indicates a lapse in the facility's adherence to the mandated testing schedule, which requires this test to be conducted every 36 months. The absence of this critical test could potentially compromise the facility's ability to provide essential power during emergencies. The deficiency was confirmed during an exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025. They acknowledged the failure to perform the tri-annual 4-hour load test, which is a significant oversight in maintaining the safety and operational readiness of the facility's electrical systems.
Plan Of Correction
Facility cannot retroactively correct the missed documentation. 4-hour load test will be completed. The maintenance director will be educated on the completion of the 4-hour load test completion. An audit will be completed quarterly to ensure the 4-hour load test is completed as required. Results of this audit will be reported to the Quality Assurance Steering Committee. Facility cannot retroactively correct the missed documentation. 4-hour load test will be completed. The maintenance director will be educated on the completion of the 4-hour load test completion. An audit will be completed quarterly to ensure the 4-hour load test is completed as required. Results of this audit will be reported to the Quality Assurance Steering Committee. Facility cannot retroactively correct the missed documentation. 4-hour load test will be completed. The maintenance director will be educated on the completion of the 4-hour load test completion. An audit will be completed quarterly to ensure the 4-hour load test is completed as required. Results of this audit will be reported to the Quality Assurance Steering Committee.