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K0291
F

Failure to Document Emergency Lighting Test

Erie, Pennsylvania Survey Completed on 01-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide documentation of functional tests for battery-powered emergency lighting, which is a requirement for emergency lighting of at least 1-1/2-hour duration as per NFPA 101. During a document review on January 23, 2025, it was revealed that the facility lacked documentation for the annual 90-minute battery back-up lighting test. An interview with the maintenance supervisor confirmed that the facility could not provide evidence that the required annual test had been conducted.

Plan Of Correction

An annual 90-minute battery back-up lighting test was completed January 30, 2025. Education was provided to the Maintenance Director by the Administrator on January 24, 2025 regarding the annual 90-minute battery back-up lighting test. An audit will be completed annually by the Maintenance Director to ensure that the annual 90-minute battery back-up lighting test is completed and will be monitored by the Administrator. Results of the audit will be presented at the quarterly QAPI meeting and recommendations will be implemented.

See complete original report
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