Fire Alarm System Maintenance Deficiencies
Summary
The facility's fire alarm system was found to be inadequately maintained during a Life Safety Code survey. Specifically, the smoke detectors were not inspected and tested annually, and the heat detectors and smoke detectors located in elevator shafts were not inspected and tested every 18 months. Additionally, the batteries associated with the fire alarm panel and fire alarm system were not load voltage tested semiannually, and the Notification Appliance Control Panel (NACP) batteries failed load testing. These deficiencies affected both resident use floors and the basement of the facility. Interviews with the Maintenance Supervisor revealed that the contractor responsible for inspecting, testing, and maintaining the fire alarm system did not provide documentation of semiannual load voltage testing of the batteries. Furthermore, issues identified in the fire alarm system inspection and testing report from April 2024 were not addressed, and the contractor did not return to correct these issues. The report also noted that several resident rooms were not tested due to COVID restrictions, and the elevator shaft devices were only simulated for functionality without the elevator company present. The smoke and heat detectors in the elevator shafts had not been tested for 21 months, exceeding the maximum interval allowed by the National Fire Protection Association (NFPA) standards.
Plan Of Correction
Plan of Correction: Approved March 2, 2025 The smoke detectors missed on the annual inspection will be inspected per life safety code standards. The heat and smoke detectors in the elevator shaft not inspected and tested within the last 18 months will be inspected. This test will be coordinated with the vendors who provide elevator service and fire detection services. The batteries associated with the fire alarm panel and fire alarm system that were not load voltage tested semiannually have been tested per life safety code standards. The Notification Appliance Control Panel batteries that failed the load testing have been replaced and now operate per life safety code standards. An audit of the most recent inspection reports has been completed to assure no other heat or smoke detectors were missed and require inspection. Any areas identified as lacking inspection have been inspected per life safety code standards. A review of the facility's policy related to routine testing of building systems, to include fire systems, has been reviewed and updated to include language that clearly outlines the frequency and scope of inspections, as well as who is to complete them. The facility maintenance and administrative staff will utilize electronic calendar reminders to assist in assuring that inspection dates are occurring within the regulatory time frames. All maintenance staff will receive education and in-servicing on this new policy and procedure. An audit of the inspection reports will occur monthly, for any vendor-provided services related to smoke head testing and related fire system tests, for three months, to assure no areas are missed or that vendors return to address any missed items. The maintenance supervisor, or designee, will complete the audits. These audits will be reviewed for proper completion by the maintenance director. 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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