Elevator Maintenance and Safety Deficiencies
Penalty
Summary
The facility was found to have deficiencies related to the maintenance and operation of its elevators during a Life Safety Code recertification survey. Specifically, it was observed that the elevator machine room in the basement contained four TV screens, which are not necessary for the maintenance or operation of the elevator. This is a violation of the 2007 ASME A 17.1 Safety Code, which stipulates that only machinery and equipment used directly in connection with the elevator should be stored in such spaces. Further document review revealed that two out of three elevators serving the facility were not maintained in accordance with the NFPA 101: Life Safety Code and ASME A17.1/CSA B44: Safety Code for Elevators and Escalators. Inspection records indicated that the emergency communication systems in these elevators were not functioning properly. Specifically, the car emergency signals for two elevators were marked as 'no good' due to the absence of a dial tone on the phones, indicating a failure in the emergency communication system. The facility's failure to maintain the elevator communication systems was further evidenced by repair time tickets and vendor communications. These documents showed ongoing issues with the elevator phones, including inactive phone lines and the need for new phone installations. Despite efforts to address these issues, the facility had not submitted evidence of successful repairs by the time of the offsite Life Safety Code Post Survey, indicating a continued deficiency in maintaining the required safety standards for elevator operations.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 Plan of Correction for affected areas: The maintenance staff immediately removed the identified storage items from the Elevator machine room. The Director of Maintenance secured independent telephone lines for each elevator and engaged our Elevator vendor to install, test and maintain the emergency telephones in each elevator. Plan of Correction to identify other areas potentially affected: The facility acknowledges that all residents have the potential to be affected by this practice. All Elevator machine rooms were checked for storage not directly related to the elevator use. Any items found were immediately removed. Plan of Correction for system measures to prevent reoccurrence: A “Storage is Prohibited” sign was permanently installed on the Elevator Machine Room Door. All maintenance staff will receive additional education, and all participants will understand the life safety issues with Elevators in accordance with the requirements of 2012 NFPA 101:19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4 and ASME A17.3, Safety Code for Existing Elevators and Escalators. The In-Service Coordinator/designee has been assigned the responsibility for the education of staff. This education will also be provided to all new Maintenance staff and will be reviewed when concerns are identified. The Director of Maintenance or designee will inspect all Elevator machine rooms for improper storage and test the Emergency telephones in each elevator monthly. The Director of Maintenance will utilize an audit tool to document the findings and report the audit findings to the Quality Assurance/Quality Improvement Committee monthly for a period of six (6) months. Plan of Correction for monitoring corrective actions: The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the audits to the Quality Assurance/Quality Improvement Committee on a monthly basis for 6 months, as well as correction plan if warranted. Responsibility: Director of Operations Compliance Date: January 27, 2025