Failure to Test Smoke Detectors
Penalty
Summary
The facility failed to conduct functional testing of smoke detectors within the previous twelve months, affecting three out of 43 smoke compartments. This deficiency was identified during a document review and interview conducted on December 16, 2024. The specific rooms where smoke detectors were not functionally inspected include rooms 2981, 2998, 3918, 4917, 4965, and 4966. The Assistant Director of Facilities and Grounds confirmed during the interview that the smoke detectors in these rooms had not been tested within the required timeframe.
Plan Of Correction
1. The smoke detectors were functionally inspected in the previous twelve months, in the following rooms on 07/03/2024 and placed in the Life Safety book: a) 2981; b) 2998; c) 3918; d) 4917; e) 4965; f) 4966; 2. Maintenance staff will be educated that smoke detectors will be functionally inspected every twelve months. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building to ensure that smoke detectors are functionally inspected every twelve months as well as the Life Safety book is reviewed semi-annually. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.