|Electrical Equipment - Testing and Maintenance Requirements|
The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8
Name: MAIN BUILDING - Component: 01 - Tag: 0921
Based on document review and interview, it was determined the facility failed to provide documentation verifying battery powered emergency lighting testing, affecting eight of eight smoke compartments within the component.
1. Review of documentation on September 16, 2019, between 8:00 AM and 9:15 AM revealed the facility lacked documentation, verifying the following:
a. a 90-minute test of the batteries supplying power to the units, within the previous twelve months;
b. monthly visual bulb operation inspections, for the previous full twelve months.
Interview with the Maintenance Assistant on September 16, 2019, at 9:15 AM confirmed the facility could not verify the testing had occurred.
| ||Plan of Correction - To be completed: 10/29/2019|
The maintenance director/designee will ensure that 90 minute testing is completed as required on battery powered emergency lighting. The maintenance director/designee will ensure that monthly bulb testing is completed as required on emergency lighting. The maintenance director will ensure that documentation of both are present and maintained. The maintenance director/designee will audit compliance with testing of emergency lighting battery and bulb weekly. After 1 month, the maintenance director/ designee will audit the testing of the emergency lighting battery and bulb test monthly. The results of the audits will be reported to the facility QAPI meeting x 1 month.