Fire Alarm Panel Repair and Documentation Deficiency
Penalty
Summary
The facility failed to ensure that certified personnel completed repair work on the fire alarm panel, which had been in trouble due to a power failure for approximately two months. The issue was not related to the battery, and partial repairs were attempted by non-certified personnel. During the survey, it was observed that the fire alarm panel remained in trouble, indicating that the repairs were not successful or complete. Additionally, the facility did not provide documentation of functional testing after the repair work was completed, nor did they provide a record of completion for the repairs. This lack of documentation and testing was confirmed during an interview with the Administrator and Director of Maintenance, who acknowledged the ongoing trouble with the fire alarm panel and the incomplete repair process.
Plan Of Correction
1) The facility will have the fire panel inspected by certified personnel from Sciens Building Solutions to ensure completed repair work to the fire alarm panel is functional. Sciens Building Solutions will provide documentation of functional testing after repair certification to the fire alarm panel and provide a record of completion of inspection of repair to the fire alarm panel. 2) Maintenance director and Administrator will be educated that all repairs to the fire panel must be completed by certified personnel. 3) Maintenance Director/Administrator will ensure certified repair personnel work on fire panel and suppression system by auditing credentials of repair technician before any repairs are completed to fire safety system. Results of the audits will be reviewed at monthly QAPI for any trends and further recommendations. 4) Sciens Building Solutions will start inspection of fire control panel 01/10/2025. Corrective action will be completed by 02/10/2025.