Failure to Test Fire Alarm System Devices Annually
Penalty
Summary
The facility failed to ensure that all devices associated with the fire alarm system were maintained and tested annually in accordance with NFPA 101 and NFPA 72 standards. During a life safety recertification survey, it was observed that the facility's maintenance logs did not include documentation of annual testing for the magnetic fire/smoke barrier doors' hold open devices and the magnetic delayed egress locks. The last recorded service by the vendor occurred on three separate occasions, but none included the required testing of these specific devices. This deficiency was confirmed during an interview with the Director of Maintenance, who acknowledged the oversight and stated that the vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - Facility contracted fire alarm vendor was contacted via telephone on 3/14/25 and informed that hold open devices and magnetic egress locks are required to be tested annually as per NFPA 101 and NFPA 72 and such testing was not included as part of the vendor conducted inspections. - Facility contracted fire alarm vendor was asked to complete a full house test of all hold open devices and magnetic egress locks. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All residents have the potential to be affected; however, no residents were negatively impacted. Element #3: The following system changes will be implemented to prevent reoccurrence: - The facility policy and procedure on Fire Alarm System Testing and Inspection was reviewed and revised to include testing of all hold open devices, magnetic fire/smoke barrier doors, and magnetic delayed egress locks. - Maintenance staff will be re-educated on the fire alarm system testing requirements by the administrator, and a record of education will be maintained for reference and validation. - Facility contracted fire alarm vendor will include in all inspection reports the location and inspection of all doors with magnetic egress locks and hold open devices that are released upon fire alarm activation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Maintenance has created an audit tool to ensure that fire alarm system testing and inspection documentation is completed and validate that all required doors/magnetic devices are included in the documentation maintained on file. - The Director of Maintenance/designee will audit monthly for 3 months. Negative findings will be immediately reported to the administrator. - Results of audits will be reviewed during monthly QAPI meetings, and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25.