Failure to Test Duct Detectors in Fire Alarm System
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with the National Fire Protection Association (NFPA) 101 standards. During a revisit survey, it was found that the biennial smoke detector sensitivity test, conducted on 56 devices on February 26, 2025, did not include the testing of 18 duct detectors. This oversight was confirmed during a record review and staff interview with the Maintenance Director, who acknowledged the findings. The deficiency highlights the facility's failure to ensure the proper operation of the fire alarm system, which is crucial for preventing delayed alarm activation or failure under hazardous conditions. The lack of documentation for the testing of the duct detectors indicates a gap in the facility's compliance with the NFPA 101 and NFPA 72 standards, which could potentially lead to serious consequences in the event of a fire emergency.
Plan Of Correction
K345 Fire Alarm System Testing and Maintenance 1. The fire alarm inspection was conducted for sensitivity test on ducks and is currently up to date. 2. Completed audit was conducted and any abnormal findings were corrected. 3. A. Vendor has the facility on schedule to do inspection based on F345 B. Education with the maintenance department for K345 4. Monthly audits for K345 will be conducted and findings will be brought to QAPI. K345 Fire Alarm System Testing and Maintenance 1. The fire alarm inspection was conducted for sensitivity test on ducks and is currently up to date. 2. Completed audit was conducted and any abnormal findings were corrected. 3. A. Vendor has the facility on schedule to do inspection based on F345 B. Education with the maintenance department for K345 4. Monthly audits for K345 will be conducted and findings will be brought to QAPI.