Deficiency in Kitchen Hood Extinguishment System Maintenance
Summary
The deficiency identified during the Life Safety Code survey pertains to the maintenance of the kitchen hood extinguishment system in the facility's basement kitchen. The system was not inspected every six months as required. The Maintenance Supervisor revealed that the contractor responsible for inspecting, testing, and maintaining the system was scheduled to perform an inspection in 2023. However, due to a transition between companies, the inspection was not completed as scheduled. The system was last inspected on March 9, 2023, and October 6, 2023, with issues cited in the October report being corrected by a re-inspection on October 16, 2023. Additionally, the manual pull station for the kitchen hood extinguishment system was not inspected monthly, as required. During an observation in the basement kitchen, it was noted that the tag attached to the manual pull station lacked documentation for monthly inspections for October, November, and December of 2024. The Maintenance Supervisor admitted to being unaware of the requirement for monthly inspections of the manual pull station, and there was no documentation available for these inspections in the facility's records. This oversight was confirmed by reviewing the Fire Extinguisher Monthly Checklist, which also lacked documentation for the required monthly inspections.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 The hood extinguishment system identified during survey as having not been inspected every six months, has had timely inspections since the occurrence in 2023, per life safety code standards. The manual pull station for the hood extinguishment system pull station identified as lacking the required monthly inspection has been inspected and is working properly. The facility has only one hood extinguishment system, so there is nothing further affected by the deficient practice. An audit of the facilities pull-stations will be completed to identify any others that may have lacked monthly inspections. Any identified as having been missed will be inspected per life safety code standards. A review of the policy related to inspections of the hood extinguishment system and pull stations has been completed with updates made to specify frequency and documentation of inspections. All maintenance staff will receive education and in-servicing on this new policy and procedure. Audits of the monthly pull-station inspection will be completed to assure all pull-stations are inspected, including the hood extinguishment system, for three months to assure ongoing compliance. Audits of the hood extinguishment system’s six-month inspections will occur via electronic calendar reminders to the maintenance supervisor and administration, as a mechanism to assure scheduled inspections are not missed. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.
Penalty
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