Fire Alarm System Documentation Deficiency
Penalty
Summary
The facility failed to meet the fire alarm system requirements as outlined by NFPA 70 and NFPA 72, which are essential for ensuring safety in healthcare occupancies. During a document review on October 31, 2024, it was discovered that the facility did not have documentation for the semi-annual visual inspection of the fire alarm system and the sensitivity testing of the smoke detectors. This lack of documentation was confirmed in an interview with the administrator and maintenance supervisor, indicating a lapse in maintaining the necessary records for fire safety compliance. During an onsite revisit survey on December 17, 2024, the facility still failed to provide documentation for the sensitivity testing of the smoke detectors. The facility had contacted the vendor to verify whether the test was completed or needed to be completed, but at the time of the survey, the issue remained unresolved. This was confirmed in an interview with the chief operating officer and administrator, highlighting a continued deficiency in meeting the fire alarm system requirements.
Plan Of Correction
Corrective Action Taken: 1. The semi-annual visual inspection of the fire alarm system was completed on December 13, 2024. 2. The sensitivity testing of the smoke detectors has been scheduled for January 8, 2024. Systemic Changes: 1. The facility has implemented a tracking system to ensure timely scheduling and documentation of all fire alarm system inspections and testing. 2. The maintenance supervisor will review the schedule monthly to verify compliance with inspection and testing requirements.