The University inspects, tests, and maintains emergency power systems in accordance with the Joint Commission Environment of Care Standard EC.02.05.07 for the following facilities and equipment:
Bldg. 925, Hollings Cancer Center, Generator #1 (750-01-01), Generator #3 (925-01-144) Bldg. 148, 135 Cannon St., Generator #1 (148-08-251)
Bldg. 750, Psych Inst., Generator #1 (750-01-220), Generator #2 (750-01-221) Bldg. 180, Family Med., Generator #1 (180-08-207)
The following is quoted from the Joint Commission standards for reference:
EC.02.05.07: The Hospital inspects, tests, and maintains emergency power systems.
EC.02.05.07.04: Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests each emergency generator for at least 30 continuous minutes. The completion dates of the tests are documented in the generator and ATS testing logs by the technicians performing the tests. EC.02.05.07.05: The Hospital’s emergency generator tests are conducted with a dynamic load that is at least 30% of the nameplate rating of the generator or meets the manufacturer’s recommended prime movers’ exhaust gas temperature. If MUHA does not meet either the 30% of nameplate rating or the recommended exhaust gas temperature during any test in EC.02.05.07 EP 4, the Facilities Maintenance Department will test each emergency generator once every 12 months using supplemental (dynamic or static) loads of: 25% of nameplate rating for 30 minutes, followed by 50% of nameplate rating for 30 minutes, followed by 75% of nameplate rating for 60 minutes, for a total of 2 continuous hours. If required, the completion date of the tests is documented in the generator and ATS testing logs by the technicians performing the test.
EC.02.05.07.06: Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests all automatic transfer switches. The completion date of the tests is documented in the generator and ATS testing logs by the technicians performing the tests.
EC.02.05.07.07: At least once every 36 months, hospitals with a generator providing emergency power for the services listed in Standard EC.02.05.03 EP’s 5 and 6 must test each emergency generator for a minimum of 4 continuous hours. The completion date of the tests is documented in the generator and ATS testing logs by the technicians performing the tests.
EC.02.05.07.07: The 36-month emergency generator test uses a dynamic or static load that is at least 30% of the nameplate rating of the generator or meets the manufacturer’s recommended prime movers' exhaust gas temperature.
EC.02.05.07.09: If a required emergency power system test fails, the hospital implements measures to protect patients, visitors, and staff until necessary repairs or corrections are completed.
Definitions:
Generator: A machine that generates electrical power and is configured to automatically start when a power failure occurs from the Electric Utility.
Emergency Power Standby System (EPSS): One or more generators that are connected to a building’s emergency distribution system by the means of Automatic Transfer Switches.
Automatic Transfer Switch (ATS): An electrical switching device that, on a loss of normal incoming power, will automatically request an Emergency Power Standby System (EPSS) to start and, once emergency power is produced, transfer the load from the normal source to the generated emergency source.
Generator System Log Book: A binder containing individual generator and ATS testing log sheets. Computerized Maintenance Management System (CMMS): The Computerized Maintenance
Management System is a computer software system that maintains a computerized record of equipment and systems, calculates preventive maintenance due dates and provide reminders to perform tasks as programmed in a given facility. The system also provides a means to generate work order or work request tickets to track requests received by customers requiring service.
Purpose:
This procedure is intended to establish the process whereby the Emergency Power Standby Systems serving Joint Commission related University facilities that contain clinical operations are tested and maintained.
General:
Power disruptions, small or large, can have a serious impact on the ability to perform critical care for our patients. The Emergency Power Standby System in each of our facilities is designed to provide
emergency power in case of an electrical utility failure. These systems provide the critical power for fire and life safety, patient critical care systems, and critical equipment. Maintenance and testing of this equipment within the requirements of the Joint Commission mandates is considered to be one of the Facilities Maintenance group’s highest priorities. The detection and reaction to power failures is covered under Policy 300.00 System Failure Protocol. This procedure will specifically address testing and maintenance to ensure the EPSS functions properly in the event of these failures.
Generator Inventory and Generator System Log Books
1. Each Generator is identified in the Computerized Management System Inventory. 2. Each building shall have a Generator System Log book.
3. Each Generator System Log Book shall contain:
B. A log sheet for each Generator in the system for each test performed C. An ATS summary log that summarized the individual ATS test log sheets D. A log sheet for each ATS in the system for each test performed
E. Any annual load test log sheets F. Any tri-annual load test log sheets
4. Each calendar year, a new Generator System Log Book is created for each generator system.
5. Prior year Generator System Log Books will be kept for no longer than 3 years in archives.
Automatic Transfer Switch Inventory and Testing Logs
1. Each Automatic Transfer Switch (ATS) is identified in the Computerized Maintenance Management System Inventory.
2. Each Automatic Transfer Switch will have identification showing the Emergency Power Standby System Generator(s) that it is connected to.
3. A listing of the ATS equipment will be kept in the Generator System Log Book as well as the ATS testing log sheets.
4. An ATS log sheet will be added to the Generator System Log Book for each ATS test. 5. An ATS summary log sheet will summarize all the ATS tests in the Generator System Log
Book.
Generator Testing Intervals
1. To meet The Joint Commission requirements, at intervals of not less than 20 days and not more than 40 days, the hospital tests each emergency generator for at least 30 continuous minutes. The completion dates of the tests are documented in generator testing logs by the technicians performing the tests.
2. During loaded runs, it will be the electrical shop’s intention to add the static or dynamic load necessary to reach at least 30% of the nameplate value for each Generator.
3. If testing does not meet either the 30% of nameplate rating or the recommended exhaust gas temperature during any test noted above, test each emergency generator once every 12 months using supplemental (dynamic or static) loads of:
4. At least once every 36 months, a generator providing emergency power for the services listed in Standard EC.02.05.03 EP’s 5 and 6 will be tested for a minimum of 4 continuous hours. The completion date of the tests is documented in the generator testing logs by the technicians performing the tests.
ATS Testing Intervals
1. Twelve times a year, at intervals of not less than 20 days and not more than 40 days, test all automatic transfer switches.
2. The completion date of the tests is documented in the ATS testing logs by the technicians performing the test and kept in their appropriate Generator System Log Book.
3. During each generator system test, the technician will document which Automatic Transfer Switch was used to initiate the test and each ATS that was transferred on the ATS log sheet.
4. At least one time per year, each ATS will be tested to start the generator system as part of the Generator testing.
Failed Tests
1. If a required emergency power system test fails, the testing technician shall report it immediately to the Electrical Shop Supervisor or designee.
2. The Electrical Shop Supervisor will notify the University Maintenance Manager and the MUHA Infrastructure Systems Manager of the nature of the failure. If the problem is readily found and is resolved immediately, a repeated test will be scheduled as soon as possible. If there is any concern for the generator’s functionality, then proceed to step three.
3. If the problem is not readily known and repairable, the Electrical Shop Supervisor, the University Maintenance Manager and MUHA Infrastructure Manager will take steps to implement
measures to protect patients, visitors, and staff until necessary repairs or corrections are completed.
4. The same process shall be used in case of any related ATS switch’s failure to transfer or provide a start signal to the generator.
5. If needed, Facilities Maintenance will have a temporary generator delivered and the load connected to the temporary generator until the building system is repaired and tested to function properly.
Reporting Generator System Failures to the EOC and Clinical Staff
1. If, during testing or scheduled maintenance, emergency power is known to be unavailable for any length of time, it will be reported to the MUHA Infrastructure Manager or MUHA Electrical Shop Supervisor who will notify the EOC Chairman and the Clinical Communication
Coordinator so appropriate clinical work-around activities can be put in place.
2. If the system cannot be restored immediately, a temporary generator to provide emergency power will be put in place and connected to the inoperable emergency system’s load. 3. The temporary generator will be tested once it is connected and clinical operations will
permitted to be performed.
4. The temporary generator will remain in place until a successful test of the building system is completed.
5. During times a temporary generator is used, the temporary generator will be tested within the same intervals and tested and logged as if it was part of the building system.
Review of Testing and Maintenance of Each Generator
1. Each week, an Electrical Shop Supervisor shall review the documents for accuracy and any anomalies in data that was recorded by the technician on the testing logs.
2. If any data is missing or illegible or errors are found, the Supervisor shall contact the original testing technician and review the test information with them. If the testing log needs to be changed or corrected, the original testing technician shall indicate their agreement with the change on the document by signing their initials.
3. Every three (3) weeks or twenty-one (21) days, the Electrical Shop Supervisor shall review the Generator logs for accuracy. If any data is missing or illegible or errors are found, the Electrical Shop Supervisor shall contact the original testing technician and review the test information with them. If the testing log needs to be changed or corrected, the original testing technician shall indicate their agreement with the change on the document by signing their initials.
4. If any of the tests are deemed to be invalid, the Electrical Shop Supervisor will consult with the University Maintenance Manager and may require additional testing to be done in order to remain compliant within the intervals outlined above.
Auditing of Generator Log Books
1. Every month or thirty (30) days, the University Maintenance Manager shall review the Generator logs for accuracy. If any data is missing or illegible or errors are found, the Electrical Shop Supervisor, and the original testing technician shall review the test information.
deemed to be invalid, the University Maintenance Manager may request additional testing to be performed to maintain compliance.
3. Discrepancies found during the auditing process shall be documented for the Director of Facilities Operations.
4. Due to the critical nature of maintaining full compliance of these systems with testing,
maintenance, and documentation, personnel who fail to comply with this procedure are subject to disciplinary action under the appropriate Human Resource disciplinary policy.
Appendix 1: Generator Testing Templates
Generator Testing Log Template
http://academicdepartments.musc.edu/vpfa/eandf/ef_staff/forms/policy_procedure/300-399/301_Gen_Log.pdf
Automatic Transfer Switch Log Template
http://academicdepartments.musc.edu/vpfa/eandf/ef_staff/forms/policy_procedure/300-399/301_ATSLog_Template.pdf
Please Note: these forms can be found in our in-house forms page:
http://academicdepartments.musc.edu/vpfa/eandf/ef_staff/forms.htm
________________________________________________________________________________ ___ Note: This Policy, like all other policies within Engineering and Facilities is not a contract and should not be relied upon as such. Questions concerning Interpretation of this document or suggestions for improvement should be directed to MUSC Facilities and Engineering.
Approved By: Effective Date:
Greg Weigle Mark Brown September 12, 2012
