Failure to Perform Emergency Lighting Tests at Generator
Penalty
Summary
The facility failed to perform the required functional tests of the battery-powered emergency lighting source at the generator, which serves the entire component. During an observation on October 8, 2024, it was noted that the facility did not conduct the battery back-up emergency lighting test at the generator for 30 seconds monthly and 90 minutes annually. Additionally, the emergency light was found not mounted and was instead laying on an electrical duct. This deficiency was confirmed through an interview with the Director of Maintenance on the same day. A follow-up observation on December 9, 2024, revealed that the issue had not been corrected. The emergency lighting test had still not been performed, and the light fixture remained unmounted. The Director of Maintenance confirmed during interviews on December 9, 2024, that the deficiency identified in the initial observation had not been addressed.
Plan Of Correction
1. The facility is unable to retroactively conduct a 30-second monthly test or 90-minute annual test of the battery backup emergency lighting in the generator room before the survey. 2. The facility had a new Maintenance Director that started on 12/09/24. Maintenance or Designee will conduct a 30-second monthly test and a 90-minute annual test of the battery backup emergency lighting. The 90-minute test will be completed by 01/27/2025. Battery will be replaced as necessary. 3. Education will be provided to Maintenance staff regarding testing of the battery backup emergency lighting. Documentation of testing will be maintained in the Life Safety Book per regulation. 4. Maintenance Director or Designee will complete audits of routine testing monthly until substantial compliance has been achieved and quarterly thereafter. 5. Results of the audits will be presented to the QAPI committee for review and analysis for continued monitoring.