Lack of Fire Alarm System Impairment Policy
Summary
The facility failed to ensure occupant safety during a period when the fire alarm system was impaired for more than four hours. During a life safety survey, it was discovered that the facility lacked a policy and procedure outlining the necessary actions to be taken if any part of the fire alarm system was out of service. This deficiency was identified during a document review of the facility's maintenance, inspection, and testing records. The absence of such a policy meant that there were no predefined measures to protect occupants in the event of a fire alarm system failure, leaving them potentially unprotected during the impairment period.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Corrective Action: On (MONTH) 12, 2025, the facility developed a comprehensive policy and procedure to outline the actions to be taken in the event of any impairment to the fire alarm system. The policy includes: - Immediate notification procedures for staff, residents, and local fire authorities. - Temporary fire watch procedures, as per NFPA 101, Life Safety Code guidelines. - Vendor contacted to correct impairment. - Documentation of the impairment and actions taken. Element 2 Residents at Risk: While no residents were affected by this practice, the potential existed for all residents to be affected by this deficient practice. Element 3 Systemic Changes: A policy and procedure on Fire Watch was created. All maintenance and administrative staff will be trained on the newly developed fire alarm impairment policy. An updated maintenance checklist will be implemented to include a review of the fire alarm system and a requirement to verify that the impairment procedures are readily available. The facility contracts with a vendor to perform routine inspections and testing to proactively prevent system impairments. An audit was created to monitor compliance with the requirements of a Fire Watch. Element 4 Monitoring: The maintenance director will conduct monthly audits of fire safety documentation to ensure adherence to the fire alarm impairment policy. Results of the audit will be reported to the administrator monthly. Any deficiencies identified during the audits will be addressed immediately, and retraining will be provided if necessary. The results of the audit will also be reported quarterly to the QAPI Committee for two quarterly meetings. The QAPI Committee will determine if further action is required. Element 5 Person responsible: The Maintenance Director.
Penalty
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