Fire Alarm System Deficiency Due to Unresolved Signal Issues
Penalty
Summary
The facility failed to meet the fire alarm system requirements as evidenced by a document review and interview conducted on February 4, 2025. The fire alarm inspection report, completed on October 14, 2024, identified two deficiencies that were not addressed by the time of the survey. Specifically, the Digital Alarm Communicator Transmitter (DACT) main and DACT point did not receive signals from the fire system, indicating a failure in the communication link between the fire alarm system and the monitoring station. An interview with the maintenance supervisor confirmed that these deficiencies were not corrected at the time of the survey. This lack of corrective action suggests a lapse in the facility's maintenance and testing program for the fire alarm system, which is required to comply with NFPA 70 and NFPA 72 standards. The failure to address these deficiencies could potentially compromise the safety and emergency response capabilities of the facility.
Plan Of Correction
The facility was provided with incorrect documentation by the inspection company. The company has provided the correct documentation depicting that there were/are no deficiencies present. The above-mentioned documentation will be provided upon submission of this Plan of Correction. The Maintenance Director will be educated on the importance of ensuring that the facility receives correct/accurate reports regarding any inspections that occur. All inspections/reports will be audited by the administrator and reviewed with the inspection companies prior to them exiting the facility. Once the written reports are obtained, the administrator and/or Maintenance Director will again review to ensure accuracy of findings. The results of inspections will be reviewed at the facilities monthly Quality Assurance and Performance Improvement Meeting. The facility was provided with incorrect documentation by the inspection company. The company has provided the correct documentation depicting that there were/are no deficiencies present. The above-mentioned documentation will be provided upon submission of this Plan of Correction. The Maintenance Director will be educated on the importance of ensuring that the facility receives correct/accurate reports regarding any inspections that occur. All inspections/reports will be audited by the administrator and reviewed with the inspection companies prior to them exiting the facility. Once the written reports are obtained, the administrator and/or Maintenance Director will again review to ensure accuracy of findings. The results of inspections will be reviewed at the facilities monthly Quality Assurance and Performance Improvement Meeting.