Fire Alarm System Maintenance Deficiencies
Summary
The facility's fire alarm system was found to be inadequately maintained during a Life Safety Code survey. The survey revealed that not all fire alarm system devices were functionally tested annually, as required. Specifically, a review of the Fire Alarm Inspection and Test Reports from an outside contractor showed that only half of the system's devices were tested on two separate dates, with some devices only receiving a visual inspection and others not tested at all. Additionally, there was no documentation of sensitivity testing for smoke detectors, and some smoke detectors lacked addresses, indicating they were non-addressable and required sensitivity testing. The Maintenance Director, who had been in the position for less than two weeks, was unaware of these issues. Further findings included the failure of four horn/strobe devices during testing, which had not been repaired or replaced. The facility lacked documentation from the fire alarm system manufacturer regarding the need for sensitivity testing and had no policy or procedure specific to the maintenance of the fire alarm system. Interviews with the Maintenance Director and the Administrator confirmed the absence of necessary documentation and awareness of the system's deficiencies. The facility's fire alarm system issues affected all resident use floors in both the front and rear buildings.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 Documentation was obtained on which exact smoke detectors were fully addressable and which were conventional, and all conventional detectors had sensitivity testing conducted on 2/24/25. The four horn/strobes that failed in the 2/7/24 fire inspection report were replaced on 2/24/25. The 21 heat detectors, the one duct detector, and one remote annunciator will be inspected/tested. A review of all fire alarm inspection and testing reports was conducted to ensure all fire alarm system components have been inspected, tested, and maintained per all applicable codes. The Maintenance Director was educated on the NFPA requirement to ensure the fire alarm system is maintained and tested at required intervals, including sensitivity testing and fire alarm system devices functional testing. The policy and procedure was reviewed again, and no changes were made. An audit tool was created to ensure proper scheduling is completed for all required testing and inspection and to ensure that any failed devices are repaired or replaced. Audits on the testing log book will be conducted monthly x4 by the Maintenance Director. Results of the audit will be reviewed at QAPI. The Director of Maintenance is responsible for the plan.
Penalty
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