Egress Lighting Deficiency Due to Timer Control
Penalty
Summary
The facility failed to ensure continuous illumination of the means of egress, as required by the 2012 NFPA 101 standards. During a life safety survey conducted on December 3, 2024, it was observed that the lighting at the first-floor exit discharge at the West stair and the adjacent dining room exit was controlled by a timer. This setup did not comply with the requirement for continuous illumination, as the lights were not operable without the use of a timer. The deficiency was identified through both observation and interview, where the Facilities Director acknowledged the issue. The lighting arrangement at these egress points did not meet the standard that requires illumination to be continuous during occupancy and not compromised by energy-saving devices like timers. The failure to provide continuous lighting could potentially affect the safety of the egress paths, although the report does not specify any direct consequences or risks that occurred as a result of this deficiency.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Correction: 1) On 12/4/2024, the timers that controlled the lighting at the West stairs were immediately deactivated and replaced with photocell sensors. 2) The new photocell sensors now ensure that the lighting remains continuously operational, without the need for manual intervention, and fully meets the requirements. 3) The newly installed photocell sensors were tested on-site to confirm that the egress lighting now operates continuously during hours of occupancy, in compliance with the required illumination standards. The lighting was inspected to ensure that no failure of any single lighting unit resulted in an illumination level of less than 0.2 ft-candle in any designated area. 4) The Director of Maintenance documented the replacement of the timers and the installation of photocells, confirming that all lighting in the means of egress is now continuously illuminated. Identification of Others: 1) A comprehensive review of all lighting systems controlling means of egress throughout the facility was conducted to identify any additional instances where timers or other manual control systems might be in place. This included all exit access areas such as corridors, stairs, aisles, and exits. Systemic Changes: 1) As a systemic change, the facility will ensure that all areas requiring illumination of egress pathways are equipped with photocell sensors to guarantee that lighting will remain continuously on, even if power is lost or if there is a failure of an individual lighting unit. 2) The Facility Director will ensure that all maintenance and operations staff are trained in the requirements, specifically regarding continuous illumination for means of egress. This training will emphasize the proper installation and maintenance of lighting systems and photocell sensors. Quality Assurance (QA): 1) The Director of Maintenance will implement a monthly audit tool to verify that all means of egress lighting remain continuously operational and is in compliance. The audits will include checking that photocell sensors and lighting units function properly without any timers or manual switches. 2) Audits will be completed by the Director of Maintenance weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 3) Findings will be brought to the QAPI meeting for tracking of facility compliance. Person Responsible for this Ktag: The Director of Maintenance will have direct oversight of the implementation and effectiveness of the corrective action plan.