Failure to Document Monthly Fire Extinguisher Inspections
Penalty
Summary
The facility failed to provide documentation verifying that portable fire extinguishers were visually inspected on a monthly basis within the previous twelve months. This deficiency affected one of two smoke compartments within the component. Specifically, a review of documentation revealed that the 2nd floor portable fire extinguisher located within the H.R. Office had not been visually inspected since November 26, 2024. An interview with the Director of Operations confirmed the lack of documentation for monthly visual inspections of portable fire extinguishers over the last twelve months.
Plan Of Correction
The fire Safety instructor inspected and documented the 2nd floor portable fire extinguisher. All fire extinguishers in the facility will be inspected for proper documentation to verify that they were visually inspected on a monthly basis within the last twelve months. Director of Operations or designee will complete monthly audits of each portable fire extinguisher in the facility to ensure they are properly inspected and documented. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. Decreasing of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.