Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which is crucial for the safety and operation of the entire facility. During a document review, it was found that the facility could not provide documentation for several critical tests and inspections. These included the weekly inspection of battery voltage, monthly testing of battery conductance, monthly testing of the generator under load, monthly operation of the automatic transfer switch (ATS), and an annual 90-minute load bank test. Additionally, there was no evidence of preventative maintenance indicating the absence of wet stacking. The lack of documentation was confirmed during an exit interview with the Maintenance Director. This deficiency indicates that the facility did not adhere to the required maintenance and testing protocols as outlined by NFPA standards, which are essential for ensuring the reliability of the emergency power system. The failure to maintain proper records and conduct necessary inspections and tests could potentially compromise the facility's ability to provide essential services during a power outage.
Plan Of Correction
Facility will maintain and inspect the emergency generator, affecting the entire facility. a. Weekly inspection of battery voltage was completed. Maintenance Director will audit weekly x4 then monthly x2. b. Monthly testing of battery conductance was completed. Maintenance Director will audit weekly x4 then monthly x2. c. Monthly testing of the generator under load was completed. Maintenance Director will audit weekly x4 then monthly x2. d. Monthly operation of the ATS was completed. Maintenance Director will audit weekly x4 then monthly x2. e. Annual 90 minute load bank was completed. Maintenance Director will audit weekly x4 then monthly x2. f. Preventative maintenance of wet stacking was completed by Powerhouse Company. All documents are added to our Life Safety Book.