Name: MAIN BUILDING - Component: 01 - Tag: 0293
Based on document review and interview, the facility failed to maintain exit signage requirements throughout the facility.
1. Document review on February 6, 2020, at 10:00 a.m., revealed the facility lacked documentation to indicate the emergency lighting deficiences noted were corrected and inspected at the time of the survey. (Last inspection was documented January 2019).
Interview with the maintenance leader and administrator on February 6, 2020, at 10:00 a.m., confirmed the above emergency lighting documentation was not available at the time of the survey.
| ||Plan of Correction - To be completed: 02/17/2020|
The last monthly inspection of emergency lighting that was reviewed at the time of February 6, 2020 survey was January 12, 2020, not January 2019 as noted in the surveyor report.
Ballasts were ordered on February 6, 2020, and are on backorder at the warehouse. Installation is to be completed on February 21, 2020 to correct the emergency lighting deficiencies. This completed work will be documented in the work order system. Emergency lighting ballasts are typically kept in stock at the center, although the backorder affected the available stock.
The applicable policy related to emergency lighting inspections/testings was reviewed, with no revisions required.
Any areas of concern related to emergency lighting discovered during routine Maintenance rounds, as well as monthly inspections/testing, are addressed. All deficiencies and corrective work is required to be documented. Documentation of all inspections, testing and maintenance related to emergency lighting is maintained in the Manager of Maintenance office.
The Manager of Maintenance is responsible for ensuring the monitoring, completion and results of all inspections, testing and maintenance of emergency lighting.
The results of the inspections, testing and maintenance of all emergency lighting will continue to be reported at the quarterly ASC EOC/LS/EM Committee. The next meeting is scheduled for February 12, 2020.