Failure to Conduct Required Fire Alarm System Testing
Penalty
Summary
The facility failed to conduct the required differential pressure testing of the duct smoke detectors as part of their fire alarm system maintenance. This deficiency was identified during a review of the facility's fire alarm inspection reports, which did not include results for this specific testing. The Maintenance Director confirmed during an interview that the testing had not been performed. This testing is a requirement under NFPA 72 (2010 edition) Table 14.4.2.2-14 (g)(6), which is crucial for ensuring the proper operation of smoke detection devices. The absence of differential pressure testing could result in the smoke detection devices failing to operate as designed in the event of a fire, thereby endangering the occupants of the building. This issue affects all smoke compartments within the facility, highlighting a significant oversight in the facility's fire safety protocols. The failure to comply with NFPA 72 standards indicates a lapse in the facility's adherence to essential fire safety regulations.
Plan Of Correction
1. Corrective Action for Cited Instance: On April 5, 2025, the facility contracted with our life safety vendor to perform differential pressure testing of all duct-type smoke detectors. This testing was completed by a certified technician on April 21, 2025. 2. Systemic Correction: A full audit of our fire alarm inspection program was completed to ensure all NFPA-required elements are included in annual inspection contracts and vendor documentation. The scope of service was updated and reviewed with the contractor on April 15, 2025. 3. Education: The Maintenance Director and backup technician were trained on NFPA 70 and NFPA 72 testing standards on April 7, 2025. 4. Ongoing Monitoring: A quarterly audit of fire alarm system documentation will be conducted by the Environmental Services Manager to ensure compliance. 5. Quality Assurance: Results and findings will be reported to the QA Committee monthly for six months, beginning April 2025, for review and revision recommendations. Completion Date: April 27, 2025