Failure to Document Monthly Testing of Elevator Firefighter's Service
Penalty
Summary
During a Life Safety Code survey, it was observed that the Firefighter's Service in the facility's two elevators was not tested monthly. This deficiency affected both elevators, which serve the basement, first floor, and second floor of the facility. An interview with the Director of Plant Operations revealed that although the in-house maintenance staff was conducting monthly tests of the Firefighter's Service, they were not documenting these tests. The Director of Plant Operations had just started working at the facility and expected the testing to be documented. Additionally, the facility had been without a Director of Plant Operations for a period from 2024 to 2025, and the Administrator was unsure if the Firefighter's Service was tested during that time.
Plan Of Correction
Plan of Correction: Approved February 5, 2025 Corrective Action for Affected Area: Director of Plant operations completed Firefighters Service on both elevators. Identification of other areas potentially affected: all residents have the potential to be affected by the same deficient practice. Both elevators had firefighters service completed. Steps to prevent further recurrence: Monthly audit to occur to ensure firefighters service is completed. Maintenance staff will be educated to ensure the firefighter's service is tested and documented for all of the facility elevators. How Corrective Action Will be Monitored: Monthly audits will be reviewed by Administrator and reported to quality assurance committee. Director of Plant operations will be responsible for compliance.