Failure to Inspect Smoke Dampers Within Required Period
Penalty
Summary
The facility failed to ensure that smoke dampers were inspected within the required four-year period, as mandated by NFPA 105, Standard for the Installation of Smoke Door Assemblies and Other Opening Protectives. During a documentation review on March 19, 2025, it was discovered that the facility lacked the necessary documentation to confirm that these inspections had been conducted. An interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director further confirmed that the smoke damper inspection documentation was not available at the time of the survey.
Plan Of Correction
1. The damper inspection was completed on 2/27/2025 and a copy of the inspection was obtained from the vendor and is maintained at the facility. 3 motors were installed 3/10/24 and all dampers had passed inspection. 2. Education was completed by the NHA to the Director of Plant Operations on keeping documents in an orderly binder. 3. The document was placed in the life safety binder. 4. TELS was updated to reflect the next 4-year scheduled inspection due date.