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 tested annually, as required by the 2012 NFPA 101 and 2010 NFPA 72 standards. During a documentation review conducted on March 20, 2025, it was observed that the fire alarm system was last serviced on July 10, 2024, and January 6, 2025. However, the service reports did not include the inspection and testing of the magnetic door hold open devices and the delayed egress devices. This deficiency was confirmed through 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 April 10, 2025 K345 I. Immediate Corrective Action: 1. Magnetic Door Hold Open Devices & Delayed Egress Devices Testing: - On 3/20/25, the Director of Maintenance immediately contacted the fire alarm service company to schedule an inspection and testing of the magnetic door hold open devices and the delayed egress devices. - The testing was conducted, and a report of the inspection and testing results of these devices has been obtained and placed in the facility’s records. II. Identification of Others: - The Director of Maintenance conducted a full review of all fire alarm service reports from the past 12 months to ensure that all devices, including magnetic door hold open and delayed egress devices, were properly tested and documented. - Any gaps in documentation were corrected, and the necessary reports were obtained. - All residents have the potential to be affected. III. Systemic Changes: 1. The Director of Maintenance updated and reviewed the facility’s fire alarm maintenance policy to ensure that all components, including magnetic door hold open devices and delayed egress devices, are tested semiannually in accordance with NFPA 101. 2. The Director of Maintenance in-serviced the maintenance staff on the updated protocols for fire alarm system testing and documentation, emphasizing the importance of comprehensive record-keeping and compliance with NFPA 101. IV. Quality Assurance: 1. An audit tool was updated to track the completion and accuracy of fire alarm system testing, ensuring that all devices are tested annually, and reports are properly documented. 2. Monthly audits for six months will begin to ensure that all devices are properly tested and documented in the annual service reports. 3. The results of the monthly audits will be reviewed during QAPI and reported quarterly. V. Person Responsible: - Director of Maintenance