Failure to Maintain HVAC System in Compliance with NFPA 80
Summary
The facility failed to maintain its heating, ventilation, and air conditioning (HVAC) system in compliance with NFPA 80 standards. During a life safety recertification survey, it was discovered that the facility's fire damper log indicated inspections and tests were conducted by a vendor, and deficiencies were noted. However, the required follow-up report detailing the corrections of these deficiencies was missing and not available at the time of the survey. In an interview, the Director of Maintenance admitted that the repairs had not been completed 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 fire damper inspection vendor was contacted on 3/24/25 and was contracted to complete a full house fire damper inspection. - Fire Damper vendor will provide a written report of any deficient areas, schedule any required repairs identified in the report, and provide documentation of such after the completion of repairs. 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: - Maintenance staff will be re-educated by the administrator on the testing and maintenance requirements for fire dampers, including ensuring necessary repairs are completed and documentation of repairs are retained. A record of education will be maintained for reference and validation. 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 damper testing, inspection, and repair documentation is completed every 4 years as required by 2010 NFPA 80. - The Director of Maintenance/designee will conduct an initial audit of fire damper inspection(s) and immediately report any negative findings to the administrator. - Results of additional inspections or repairs will be reviewed during monthly QAPI meetings, and the QAPI committee will determine ongoing audit frequency for continued compliance. Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25.
Penalty
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