Failure to Maintain Emergency Lighting Documentation
Penalty
Summary
The facility failed to maintain emergency lighting in compliance with NFPA 101 regulations, affecting the entire facility. During a document review, it was found that the facility could not provide documentation for the required emergency lighting tests over the previous 12 months. Specifically, the facility lacked records for monthly 30-second testing and annual 90-minute testing. This deficiency was confirmed through an interview with the maintenance supervisor.
Plan Of Correction
A. Monthly 30-second testing Maintenance performed emergency 30-second lighting test and documented testing results. Maintenance will maintain monthly audit of 30-second lighting testing and documentation. NHA/Designee to educate Maintenance staff by 21MAR2025 on emergency lighting 30-second testing and maintaining documentation. Maintenance Director/Designee to complete monthly x3 audit of emergency lighting test documentation. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Annual 90-min testing Maintenance will complete 90 minute annual testing by 3/21/25 and document. Maintenance will complete annual testing thereafter. NHA/Designee will educate maintenance staff by 21MAR2025 on emergency lighting 90-min testing and documenting annually to remain in compliance. NHA/Designee to complete routine audits of maintenance documentation records. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.