Observations:
Name: ASC ON 1ST FLOOR - Component: 01 - Tag: 0291
Based on document review and interview, it was determined the facility failed to perform functional tests of battery-powered emergency lighting source, throughout the component.
Findings include:
1. Review of documentation on March 22, 2023, between 8:45 AM and 10:00 AM, revealed the facility lacked documentation verifying the battery back-up emergency lighting had a 90-minute annual test.
Interview with the Administrator on March 22, 2023, at 12:00 PM, confirmed the facility could not provide documentation of the annual battery emergency light test.
| | Plan of Correction - To be completed: 03/27/2023
Plan of Correction:
The required functional 90-minute lighting test for both the battery-operated emergency lights, and emergency lights with no back up battery operated by the generator were performed by SECCO Electric Service at 4:00pm on 3/27/2023. Documentation of this test is available upon request.
To ensure 90-minute annual light test compliance, the UPMC Central PA Corporate Real Estate team will utilize a computer-based work order system (CMS). This system will prompt the Property Manager and Senior Property Manager to schedule the inspection with an electrical vendor on February 1, 2024, and all years thereafter.
To ensure sustained compliance, the Property Manager will conduct an annual audit to confirm a 90-minute light test was performed. Findings will be reported to the Senior Property Manager. Any results of non-compliance will be addressed with staff involved.
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