Helpful Hints: Top 10 Life Safety Compliance Deficiencies of 2011 - Part 7

By Steve Swedish, Windmill Software

I hope that last week's entry on K25 -Smoke Partition Construction was helpful for you.  

This week in our Top Ten Life Safety Citations from 2011 we talk about #7 - K144 Generator installation, maintenance and testing.  At the end of the blog I am going to focus on some of the most common reasons for a K144 citation. 

With Superstorm Sandy hitting the east coast 2 weeks ago, this is going to continue to be a hot topic for surveyors in the future very similar to what happened with surveys after Hurricane Katrina in 2005. Generators are the lifeline in your buildings when disaster hits, so make sure that you stay compliant with the proper testing and documentation -- the safety of your residents and staff depend on it.

The Life Safety Code for K144 reads as follows: 

Inspect all generators weekly and exercise under load for 30 minutes per month in accordance with NFPA 99, section 3.4.4.1. Maintenance and testing of essential electrical system must take place. 

The monthly testing of Level 1 and Level 2 EES needs to be conducted by one of the following two methods:

• Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
• Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
• Diesel-powered EPS installations that do not meet the above requirements shall be exercised monthly with the available EPS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30-minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
• Ensure that the start-up and or cool down times are not included in the 30-minute load test.

Maintain all records of inspections and running under load. Records should include at least:

• Date of inspection
• Time of inspection
• Generator's general condition (leaks, hoses, fuel supply, oil, belts, battery, cooling system, transfer switch)
• Start and end times of the load test including start-up time and cool-down time
• Generator output readings during load test
• Signature of individual conducting inspection, testing, or repair
• Ensure that there is battery powered emergency lighting at generator set locations inside a facility (a flashlight is not considered emergency lighting).

NFPA 99 requires an emergency generator in a health care facility when life support equipment is utilized. Monitor facility supplies to ensure that a liquid fuel supply is available for use by the emergency generator including fuels such as propane and fuel oil.

• Emergency generator sets are required to have a minimum of a 90-minute fuel supply.
• Facility must have a contingency plan and a written agreement for the resupplying of fuel in an emergency situation.
• Maintain a remote generator annunciator panel in an attended area that is staffed 24 hours a day seven days a week.
• Ensure that electrical power is transferred within 10 seconds of interruption when using a generator.

Facilities with an off-site fuel source are required to have a letter of reliability from their natural gas provider that contains:

• Statement that the fuel source is reasonable reliable
• Description supporting the reasonable reliability assertion
• Statement of the low likelihood of an interruption
• Description supporting the low interruption assertion
• Signature from technical personnel

Generator Common Citations Reasons (K144)

• Generator lacks a remote annunciator panel
• • Requirement has been in existence in a reduced form since the 1960s
  • Older installations need a minimum panel
• Audible trouble indicator
• Visual indicators for trouble and generator operation
• Storage in generator enclosures
• Indoor generators lack battery-powered task illumination
• Natural gas fueled generator lacks proof that the fuel source is reliable
• Test documentation problems
• • Visual inspections are not described
• Test must be itemized each week
• A document that shows all weekly visual inspections that can be referenced during tests and documentation review
• • Monthly load tests not completely documented
• Measurements taken from one leg only on a three phase generator
• Comment that test was more than 30% of nameplate rating with no supporting data
• Warm up and Cool down time do not count towards the 30 minutes
• Weekly inspection and routine maintenance when generator is not running needs to be very well documented

Each region is susceptible to different types of disasters. From floods and ice storms to mass power outages, making sure that your generator is properly maintained is crucial to operating a safe community for everyone. 

As I do every week, I encourage readers to share the experiences that you've had with K144 as it could help some of your peers. 

I look forward to next week when I cover #8 on the Top Ten Life Safety Citations for 2011, K50 Fire Drills. 

Sources:

Top 10 Deficiencies and How to Avoid Them, Indiana State Department of Health

Preventative Maintenance Manual, Ohio Department of Health

So That's What They Look For, CMS

This entry was written by Steve Swedish, posted on Wednesday, November 21, 2012 Bookmark the permalink. Follow any comments here with the RSS feed for this post. You can post a comment.