We are a Nursing home facility reaching the deadline for a required generator load test. Does anyone know if there is a grace period after the 36 month date? If so, how many days?
If a full facility power outage has occurred in the past 36 months, a documentation of the outage should meet the EPSS testing requirements. I have accepted that documentation. Otherwise, there is no grace period in Section 8.4.9 of NFPA 110 to be outside the 36 months time frame.
How did you surmise that the generator was to be tested under load every 36 months from the NFPA 110 requirements?
NFPA 110 recognizes two levels of equipment installation, performance, and maintenance for EPSS systems in accordance with Section 4.4.
Level 1 EPSS are mostly used in hospitals where the failure of the equipment would result in loss of life or serious injury. The patient care in typical nursing home usually do not indicate the use of Level 1 systems.
Excerpts from the applicable 2010 NFPA 110 for CMS compliance.
If you are asking about The Joint Commission, and the potential to go beyond the exact date 36 months out, I believe as part of the Joint Commission definition of Time Intervals:
Every 36 months/ every 3 years = 36 months from the date of the last event, plus or minus 45 days.
I read the Joint Commission's Life Safety and Environmental Care Standard EC.02.05.07 and did not see the words "plus or minus 45 days".
Maybe it was the surveyor's prerogative to give some leeway a based solely on record review. Not a good survey practice to do so.
Good practice would be if the surveyor had the facility do the test during the survey and evaluated the operation of the EPSS system, it would then seem reasonable not to write a deficiency based solely on documentation. Writing a citation on review of documentation only, to me, does not provide a legally defensible citation. When I conducted Life Safety Code surveys I would request the facility to test the EPSS system during the survey to ensure me all the system operational features work. If any failed, I would then write a legally defensible deficiency that included the observations, interviews, and reviews of testing documentation.
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