Failure to Provide Fire Alarm System Inspection Records
Penalty
Summary
The facility failed to ensure that records of all inspections, testing, and maintenance of the fire alarm system were provided upon request, as required by NFPA 72: National Fire Alarm and Signaling Code. During a Life Safety Code recertification survey, it was observed that the records provided for review only included a fire alarm vendor invoice dated November 1, 2024, which described services for a period from November 1, 2024, to April 30, 2025. However, a complete fire alarm system inspection report, as specified in NFPA 72: 14.6.2.4, and the last smoke detectors' sensitivity test were not available for review. The Director of Building Services stated that the fire alarm inspection and smoke detector sensitivity test had been performed the previous week and that they would request the report from the company. Despite this, no additional documentation evidencing the fire alarm system inspection was provided by the end of the survey. This lack of documentation indicates non-compliance with the requirements for maintaining and providing records of fire alarm system inspections and testing.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. Fire alarm company was called to set up sensitivity testing on (MONTH) 24th. Sensitivity testing is scheduled for (MONTH) 14th. A binder was immediately created by the Director of Maintenance to ensure proper documentation of all fire alarm systems/ smoke detectors inspections including sensitivity testing on all required equipment. The fire inspection company was called on (MONTH) 24th to forward all proof of previous inspection going back 12 months. II. Anyone has the potential to be affected. III. The maintenance department has been educated by Director of Maintenance on 2/12/25 regarding 2010 NFPA 72 14.5.3.1.2.3. IV. Facility has developed an audit tool to monitor complaint record keeping for smoke detectors and fire alarm system inspections including sensitivity testing. Audits shall be conducted after annual inspection has been completed and copy of report will be sent to Administrator by the Director of Maintenance on all system inspections. All findings will be reported to QAPI committee. V. Responsible party: Director of Maintenance/Designee.