Failure to Maintain Carbon Monoxide Detector Records
Penalty
Summary
The facility failed to comply with the requirements for testing and cleaning carbon monoxide detectors as mandated by PA Act #45. During a document review on January 22, 2025, it was discovered that the facility did not have documentation to confirm that the carbon monoxide detectors had been cleaned or tested for eight of the previous twelve months. The facility claimed that the documents were destroyed due to a water leak. This deficiency was confirmed during an interview with the maintenance supervisor on the same day.
Plan Of Correction
Maintenance immediately cleaned and tested carbon monoxide detectors throughout the building and documented the results. Maintenance completed an audit of carbon monoxide detectors throughout the facility to ensure function and documented with no negative findings. NHA/Designee to educate Maintenance department by 21MAR2025 on the importance of maintaining proper service records for cleaning/testing of carbon monoxide detectors. To prevent this from recurring, Maintenance will perform weekly x4 audits on carbon monoxide detectors for cleanliness and function. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.