Failure to Conduct Semi-Annual Fire Alarm Inspections
Penalty
Summary
The facility failed to properly maintain and inspect its fire alarm system initiating devices, as required by the 2010 edition of the National Fire Protection Association 72, National Fire Alarm and Signaling Code. During a Life Safety Code Survey, it was observed that the facility did not conduct or document semi-annual visual inspections for smoke detectors, heat detectors, and pull stations throughout the building for the calendar year 2024. Although annual functional testing was documented, the semi-annual visual inspections were not performed. The Environmental Services Director was unaware of the requirement for semi-annual visual inspections, relying solely on the vendor for inspection and testing. This oversight led to a deficiency in compliance with the NFPA 72 standards, which mandate that visual inspections occur twice per year, with a minimum of four months and a maximum of eight months between inspections.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K345 Corrective Action- The facility will ensure that it meets all the application requirements of the Life Safety Code of the National Fire Protection Association in regards to Fire Alarm System Testing and Maintenance. 1. The facility’s contracted Fire Alarm Inspection company has been contacted to perform the semi-annual visual inspection for all fire alarm system initiating devices. 2. The semi-annual visual inspection for fire alarm system initiating devices will be added to the facility’s electronic work order system. 3. The Administrator will oversee in-services to all maintenance department staff in regards to the NFPA 101 Fire Alarm System Testing and Maintenance requirements including the importance of the visual inspection for initiating devices. 4. To prevent future deficit in this practice, the Maintenance director will perform 1 audit per month for 3 months to ensure the visual inspection requirements have been met and documentation is in place. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K345.