Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0291
Based on observation, document review and interview, it was determined the facility failed to maintain required testing of back-up emergency lighting, affecting one of one location.
Findings Include:
1. Observation and documentation reviewed on December 8, 2023, at 10:30 a.m., revealed monthly 30-second testing of emergency back-up lighting inside the generator transfer switch room was not available for review.
Exit Interview with the facility Maintenance Director on December 8, 2023, at 11:00 a.m., confirmed testing of emergency lighting was incomplete.
| | Plan of Correction - To be completed: 01/11/2024
Fire and Safety Policy 301 has been updated to reflect the requirements for a monthly 30 second testing of emergency back-up lighting inside the generator transfer switch.
The policy states a monthly 30 second testing of emergency back-up lighting inside the generator transfer switch will be conducted by the Assistant Administrator. If event occurs the Assistant Administrator must submit a report to QA and Patient Safety committee.
Administrator conducted an in-service education on the updated Fire & safety Policy 301 on 1/08/24.
Governing Board, QA committee, and Patient Safety committee, will ensure compliance of expectancy of 100% benchmark.
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