Failure to Document and Perform Required Emergency Lighting Tests
Summary
During a Life Safety Code survey, it was found that the battery-powered emergency lighting in the Boiler Room of the facility was not tested monthly for 30 seconds and annually for 90 minutes as required. The facility's policy, created in December 2020, assigns the Maintenance Director the responsibility of ensuring that maintenance staff are trained and perform routine preventative maintenance tasks, including testing emergency lighting. However, there was no documentation of these tests being conducted. The Assistant Maintenance Director stated that they checked the emergency light daily using a broom handle but did not document these checks and were not instructed to do so. Additionally, they never performed the required longer test of the battery. The Administrator expected all equipment testing by maintenance staff to be documented, which was not the case here.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 The emergency lighting identified in the boiler room was comprehensively tested for 90 minutes to ensure proper function and to bring the facility back in compliance with testing requirements per NFPA 101. The testing of the emergency lighting was added to the emergency lighting test log book. An audit of the facility was completed and only one emergency light is in the facility. An audit was conducted of the emergency lighting testing log book to ensure all other emergency lighting tests are up to date in accordance with NFPA 101, specifically that ensuring that the emergency lighting will be tested 30 seconds monthly and 90 minutes annually and documentations of the tests will be added to the log book. The Maintenance Director and maintenance staff were educated on this NFPA requirement and on facility policy titled Maintenance-Preventative to ensure 30 second testing monthly and 90 minute testing annually and to keep documentation in the logbook. Testing is scheduled in accordance with NFPA 101. Audits on the testing log book will be conducted monthly x4 by the maintenance director. Results of the audit will be reviewed at QAPI. The Director of Maintenance is responsible for the plan.
Penalty
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