Failure to Conduct Timely Fire Door and Damper Inspections
Penalty
Summary
The facility failed to conduct timely inspections and testing of fire doors and fire and smoke dampers as required by NFPA 80 standards. During a records review, it was found that the last maintenance and testing reports for fire and smoke dampers were dated over four years ago, on 3/5/20, which exceeds the maximum interval of four years for testing these devices. Additionally, the inspection report for fire doors was dated 7/4/22, indicating a lapse in the annual inspection requirement. The Director of Maintenance acknowledged the backlog in maintenance tasks, attributing it to the previous maintenance director. This deficiency in maintenance practices could lead to the failure of fire and smoke dampers during fire conditions, potentially allowing the spread of fire, smoke, and gases throughout the building's smoke compartments. This oversight affects all smoke compartments within the facility, posing a risk to the safety of its occupants. The individuals responsible for performing these inspections and tests are required to have the necessary knowledge, training, or experience, and written records of these activities must be maintained and available for review.
Plan Of Correction
K761 Maintenance Inspection & Testing - Doors 1. Fire doors and fire and smoke dampers were inspected and current. 2. All fire doors and dampers were audited and inspected. 3. A. Cintas has been retained, and inspection has been placed on their schedule to maintain compliance with regulatory guidelines. B. Maintenance director and maintenance staff educated on K761. 4. Maintenance director will audit to ensure facility remains in compliance and report findings to QAPI. K761 Maintenance Inspection & Testing - Doors 1. Fire doors and fire and smoke dampers were inspected and current. 2. All fire doors and dampers were audited and inspected. 3. A. Cintas has been retained, and inspection has been placed on their schedule to maintain compliance with regulatory guidelines. B. Maintenance director and maintenance staff educated on K761. 4. Maintenance director will audit to ensure facility remains in compliance and report findings to QAPI.