Failure to Document Semiannual Fire Alarm Inspection
Penalty
Summary
The facility failed to maintain the fire alarm system as required by NFPA 101, NFPA 70, and NFPA 72 standards. During a documentation review on January 30, 2025, it was discovered that the facility could not provide documentation for a semiannual visual inspection of the fire alarm system. This lack of documentation indicates that the required inspection was not conducted or recorded, which is a violation of the fire safety standards that mandate regular testing and maintenance of fire alarm systems. An interview with the Facility Administrator and Maintenance Director on the same day confirmed the absence of documentation for the semiannual inspection of the fire alarm system and devices. This deficiency highlights a lapse in the facility's adherence to the approved program for fire alarm system maintenance, as the records of system acceptance, maintenance, and testing were not readily available as required.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Vendor was contacted when survey ended to schedule the semi annual visual inspection of the fire alarm system. 2. To prevent recurrence, Maintenance manager/designee will preschedule twice a year for the visual inspection to be completed. Administrator will be notified of those inspection dates and monitor them for completion. 3. To maintain and monitor compliance, Administrator or designee will review inspection dates and have them reported to monthly safety committee meeting, then turned into Monthly QAPI meeting.