Failure to Document Annual Emergency Lighting Tests
Penalty
Summary
The facility failed to maintain proper documentation verifying that the battery back-up emergency lighting system had undergone the required annual testing. This deficiency was identified during a document review conducted on April 22, 2025, between 9:30 AM and 11:15 AM. The review revealed that there was no documentation available to confirm that the emergency lighting system, which is supposed to provide at least 1-1/2-hour duration of lighting automatically, had been tested annually as required by NFPA 101 standards. During an exit interview on April 23, 2025, at 1:15 PM, the Chief Executive Officer and the Director of Campus Services confirmed the absence of documentation verifying the annual tests of the battery back-up lighting system. This lack of documentation affects the entire component of the emergency lighting system, indicating a failure to comply with the necessary safety standards for emergency preparedness.
Plan Of Correction
Battery back-up emergency lighting testing will be completed. Maintenance staff will be educated on completion of battery back up emergency light testing. Battery back-up emergency lighting testing will be conducted and repeated annually. Random audit will be completed quarterly to ensure that battery back-up emergency lighting testing has been completed. Results will be reported to the Quality Assurance Steering Committee. Battery back-up emergency lighting testing will be completed. Maintenance staff will be educated on completion of battery back up emergency light testing. Battery back-up emergency lighting testing will be conducted and repeated annually. Random audit will be completed quarterly to ensure that battery back-up emergency lighting testing has been completed. Results will be reported to the Quality Assurance Steering Committee. Battery back-up emergency lighting testing will be completed. Maintenance staff will be educated on completion of battery back up emergency light testing. Battery back-up emergency lighting testing will be conducted and repeated annually. Random audit will be completed quarterly to ensure that battery back-up emergency lighting testing has been completed. Results will be reported to the Quality Assurance Steering Committee.
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