Failure to Document Fire Damper Maintenance
Penalty
Summary
The facility was found deficient in maintaining proper documentation for the 4-year fire damper maintenance and exercise, as required by NFPA 101 standards for HVAC systems. During a document review conducted on December 18, 2024, between 9:15 AM and 11:00 AM, it was revealed that the facility failed to provide evidence that the necessary fire damper maintenance and exercise had been performed. This deficiency was confirmed during an exit conference with the Administrator and Director of Maintenance, who acknowledged the lack of documentation for the required maintenance.
Plan Of Correction
The facility to complete a 4 year fire damper HVAC inspection, by the facility HVAC external service provider. This inspection is scheduled for 1/15/2025. The vendor will draft a report, including the fire damper and fusible link status. The facility maintenance staff will audit annually to ensure the fire damper documentation is available in the life safety survey book for reference. The facility maintenance staff will monitor for the next scheduled inspection, anticipated on or before, January 2029. Findings from the inspection to be reported to QAPI for 3 months.