Non-Compliance with Carbon Monoxide Detector Maintenance
Penalty
Summary
The facility was found to be non-compliant with Section 915 of the 2020 Fire Code of New York State, which mandates carbon monoxide detection in buildings with fuel-burning appliances and requires ongoing preventative maintenance of these detectors. During a building tour, it was observed that the facility had fuel-burning appliances on the first floor and resident sleeping rooms on the second and third floors. Single-station battery-operated carbon monoxide detectors were present on all three floors. However, the facility's policy required these detectors to be inspected periodically, at least annually, and the manufacturer's instructions specified weekly testing and monthly vacuuming to maintain functionality. The facility's records showed inconsistencies in the number of carbon monoxide detectors logged, ranging from four to six, while the Assistant Maintenance Director confirmed there were seven detectors in total. The logs for April, May, June, and July 2024 were missing, and the Assistant Maintenance Director admitted to checking the detectors periodically without documentation. The Maintenance Director, who had been in the position for less than two weeks, acknowledged the need for weekly testing and monthly vacuuming based on the manufacturer's instructions. The Administrator expected all equipment testing by maintenance staff to be documented, which was not done in this case.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 The affected three (first, second, and third floors) of three resident use floors in the front building were tested and vacuumed to ensure they were in good working order and dust free condition. An audit was conducted to ensure the facility is in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors tested weekly and cleaned/vacuumed monthly, as recommended/required per the manufacturer and up to date. The policy and procedure was reviewed with no changes made. An inventory list of all carbon monoxide detectors was created as a result of this audit. There are carbon monoxide detectors located on all 3 resident use floors of the front building. The maintenance director and maintenance staff was educated on the Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. The maintenance director will audit all the carbon monoxide detectors monthly x4 to ensure testing is completed timely. Audit findings will be reported to the QAPI committee for review. Responsible Person: Director of Maintenance