Failure to Timely Test and Maintain Automatic Transfer Switch for Emergency Power
Penalty
Summary
The facility failed to maintain the Emergency Power Supply System (EPSS) in accordance with regulatory requirements. Specifically, the facility did not provide documentation that the automatic transfer switch (ATS) was exercised within the last 12 months, as required by NFPA 110. The last preventative maintenance and ATS service was completed on 4/17/24, which was five days past due at the time of the survey. This lapse was confirmed during a record review and interview with the Maintenance Supervisor, who acknowledged that the vendor was scheduled to perform the service the following week. This deficiency affected all 79 residents in three smoke compartments, as the ATS is critical for ensuring timely transfer of power during emergencies. The lack of timely testing and maintenance of the ATS could result in a delay in providing emergency power to selected areas of the facility, as directly stated in the report. No additional details about the residents' medical history or condition at the time of the deficiency were provided.
Plan Of Correction
K918 CORRECTIVE ACTION Maintenance Supervisor/Designee immediately contacted our backup generator service provider to follow up on service delay as we are contracted to have the generator serviced yearly. Additionally, an inservice was provided to our maintenance staff regarding the generator service and maintenance. SEE EXHIBIT - F IDENTIFICATION OF OTHERS Maintenance Supervisor/Designee immediately reviewed equipment and facility maintenance logs to ensure no other equipment was affected by this deficient practice. MEASURES TO PREVENT RECURRENCE Maintenance log reports and findings will be reviewed by the quality assurance panel during monthly and quarterly reports. Findings and suggestions for improvement will be included in the QA report. MONITORING PROCESS Maintenance Supervisor/Designee were inserviced to include the completed maintenance report findings of all regularly serviced equipment and facility inspections in our quarterly assurance meetings, including dates of upcoming scheduled maintenance. SEE EXHIBIT - G IDENTIFICATION OF OTHERS Maintenance Supervisor/Designee immediately reviewed equipment and facility maintenance logs to ensure no other equipment was affected by this deficient practice. MEASURES TO PREVENT RECURRENCE Maintenance log reports and findings will be reviewed by the quality assurance panel during monthly and quarterly reports. Findings and suggestions for improvement will be included in the QA report. MONITORING PROCESS Maintenance Supervisor/Designee were inserviced to include the completed maintenance report findings of all regularly serviced equipment and facility inspections in our quarterly assurance meetings, including dates of upcoming scheduled maintenance. SEE EXHIBIT - G