Failure to Document Fire/Smoke Damper Inspection
Penalty
Summary
The facility failed to maintain its heating, ventilating, and air conditioning (HVAC) equipment in compliance with NFPA 101 standards. During a document review, it was found that the facility did not have documentation to confirm that the fire/smoke damper inspection had been performed within the previous four years. This deficiency was confirmed during an interview with the maintenance supervisor, who acknowledged the unavailability of the required documentation at the time of the survey.
Plan Of Correction
Maintenance director and maintenance department staff educated on the deficiency and proper timeliness of maintenance. Fire/smoke damper inspection has been scheduled to be performed and will be scheduled from there on. Nursing Home Administrator will set reminder to ensure this process is completed within the appropriate range to meet regulatory standards. This process will be reviewed in our Quality Assurance Performance Improvement Plan Quarterly for Performance Improvement.