Failure to Document Semi-Annual Fire Alarm Inspection
Penalty
Summary
The facility failed to provide documentation of the semi-annual visual fire alarm system inspection, which is a requirement under NFPA 101, NFPA 70, and NFPA 72. During a document review on October 8, 2024, it was discovered that the facility did not have records of the required inspection. This was confirmed in an interview with the Director of Maintenance, who acknowledged the absence of documentation verifying that the inspection had been conducted. A follow-up observation on December 9, 2024, revealed that the issue had not been corrected, as confirmed again by the Director of Maintenance.
Plan Of Correction
1. Johnson Control was contacted to provide documentation of semi-annual visual fire alarm inspection. Per Johnson Control documentation, the fire alarm inspection was last completed on 5/15/24 and will be completed again prior to 01/06/25 in order to maintain compliance. 2. NHA and Maintenance Director will conduct semi-annual audits to ensure inspections occur as required. Maintenance Director or designee will ensure that all fire alarm reports are received and filed in the life safety book. 3. Maintenance Director will report audit results to the governing body through the QAPI Committee for review and recommendation for continued monitoring.