Fire Alarm System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its fire alarm system in compliance with NFPA 70 and NFPA 72 standards, as evidenced by a document review and interview conducted on December 30, 2024. The survey revealed two specific deficiencies: the absence of documentation verifying that a sensitivity test of smoke detectors had been performed within the previous two years, and the lack of a semiannual visual fire alarm inspection. These deficiencies were identified during a review of the facility's records at 8:40 a.m. and 8:45 a.m., respectively. An interview with the Facility Administrator and Maintenance Director at 1:30 p.m. on the same day confirmed that the facility could not provide the necessary documentation for both the semiannual fire alarm inspection and the two-year sensitivity test. This failure to maintain proper records and conduct required tests and inspections affected the entire facility, indicating a lapse in adherence to the established fire safety protocols.
Plan Of Correction
The sensitivity test of the smoke alarms is scheduled to be completed in April 2025. The semiannual visual fire alarm inspection was completed on October 31, 2024, and one is scheduled for April 2025. The Maintenance Director/Maintenance staff will be educated on the NFPA requirements of a 2-year smoke detector sensitivity test and the semiannual visual fire alarm inspection. The sensitivity test of the smoke alarms is scheduled to be completed in April 2025. The semiannual visual fire alarm inspection was completed on October 31, 2024, and one is scheduled for April 2025. The Maintenance Director/Maintenance staff will be educated on the NFPA requirements of a 2-year smoke detector sensitivity test and the semiannual visual fire alarm inspection.