Failure to Document Annual Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation verifying that fire doors within the facility had been inspected within the previous twelve months, as required by NFPA 101 and NFPA 80 standards. This deficiency was identified during a document review and interview conducted on October 8, 2024, at 11:00 AM. The review revealed that the facility lacked the necessary documentation to confirm that the fire doors had undergone the required annual inspection. An interview with the Maintenance Lead at the same time confirmed the absence of such documentation. A follow-up review and interview on December 6, 2024, at 12:00 PM, determined that the issue had not been corrected. The Manager of Plant Operations confirmed that the documentation verifying the inspection of fire doors was still missing. This ongoing deficiency affects the entire component of fire door maintenance and inspection within the facility.
Plan Of Correction
1. Doors are scheduled to be inspected 12/31/24. 2. Documentation of inspection will be maintained by the Maintenance Director. 3. Doors will be inspected monthly by a member of the maintenance team. 4. Inspection results will be reported to the Safety Committee and QAPI Committee meetings. --- 1. Doors in D Building Component 02 are scheduled to be inspected 12/31/24. 2. Documentation of the inspection will be maintained by the Maintenance Director. 3. Doors will be inspected monthly by a member of the maintenance team. 4. Inspection results will be reported to the Safety Committee and QAPI Committee meetings.