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 18.104.22.168.
Maintenance and testing of essential electrical system must take
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
- 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
- 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
- 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
- Statement that the fuel source is reasonable reliable
- Description supporting the reasonable reliability
- 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
- 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
- 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
- Comment that test was more than 30% of nameplate rating with no
- Warm up and Cool down time do not count towards the 30
- 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
I look forward to next week when I cover #8 on the Top Ten Life
Safety Citations for 2011, K50 Fire Drills.
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 Wednesday, November 21, 2012
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