Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility's fire alarm system was found to be inadequately maintained during a Life Safety Code survey. Specifically, the survey revealed that the fire alarm system's initiating devices, such as duct detectors, were not functionally tested on an annual basis as required by the 2010 edition of the National Fire Protection Association 72: National Fire Alarm and Signaling Code. The inspection and testing report from an outside contractor dated December 5, 2024, listed several deficiencies, including the inability to locate three duct detectors and the visual inspection only of another duct detector. These devices were last inspected and functionally tested in 2023, indicating a lapse in the required annual testing. Additionally, the facility failed to maintain proper documentation for the semi-annual load testing of the fire alarm system's sealed lead acid batteries. The batteries were observed to be dated from 2023, and the inspection reports indicated that they were load tested only annually, not semi-annually as required. During an interview, the Executive Director of Environmental Services was unaware of the issues with the duct detectors and stated that the batteries were load tested annually, contrary to the requirements. This lack of awareness and documentation contributed to the deficiency in maintaining the fire alarm system.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Corrective Action: Outside Contractor returned to facility on 04/04/2025 and tested the three previously missed duct detectors M1-165 Administration Board Room, M1-169 Activities, and M2-82 second floor bathing. As well as they tested duct detector M1-176 that was noted on the report as “visual inspection only.” The contractor was notified to schedule load testing every six months/semiannually on the batteries in the fire alarm system. Identify Other Residents: Director of Facilities to review all fire alarm system inspection reports since the last survey for any other missed devices/missed inspections/additional batteries. All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. Systemic Changes: Facility to revise its fire alarm service agreement to require full compliance with NFPA 72 testing standards, including mandatory documentation of device locations and test outcomes, as well as twice a year load testing of the batteries within the fire alarm system. The Director of Facilities to be educated by the Administrator on thoroughly reviewing the inspection reports after each inspection to identify any discrepancies and addressing timely. The Director of Facilities or Designee to be onsite to ensure proper completion of the annual and semiannual inspection. All maintenance staff to be educated. Monitor Corrective Actions: Director of Facilities to report the results of our recent fire alarm system inspection at our monthly MAY QAPI meeting, then moving forward the Director of Facilities will report the results of the semiannual and annual inspection to the QAPI Committee. The QAPI Committee is responsible for the ongoing monitoring and compliance. Person Responsible for Implementation: Director of Facilities