Failure to Document Fire Alarm System Testing
Penalty
Summary
The facility failed to provide documentation verifying that the semi-annual testing and inspection of the fire alarm system had occurred within the previous twelve months. This deficiency was identified during a document review conducted on April 16, 2025, between 9:00 AM and 11:15 AM. The absence of this documentation affects the entire component of the fire alarm system. During an exit conference on the same day at 1:45 PM, the Assistant Director of Nursing and the Maintenance Director confirmed the lack of documentation for the required semi-annual testing and inspection of the fire alarm system.
Plan Of Correction
1 and 2. Maintenance Director contracted Eastern Time, Inc. to revisit facility to complete semi-annual fire alarm system testing. 3. Maintenance department will be educated on the standards of the facilities fire alarm system inspection. 4. Maintenance or facility designee will audit facilities fire alarm system inspection located in the life safety book weekly x2 for 2 months then quarterly throughout the year to confirm fire alarm reports are still available for review and results of the audit will be reported to the QA Committee.