Failure to Test Fire Alarm System Devices Annually
Penalty
Summary
The facility failed to ensure that all devices associated with the fire alarm system were maintained and tested annually in accordance with NFPA 101 and NFPA 72 standards. During a life safety recertification survey, it was observed that the facility's maintenance logs did not include documentation of annual testing for the magnetic fire/smoke barrier doors' hold open devices and the magnetic delayed egress locks. The last recorded service by the vendor occurred on two occasions in 2024, but these reports did not cover the required testing of these specific devices. This deficiency was confirmed during an interview with the Director of Plant Operations, who acknowledged the oversight and indicated that the vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The Director of Maintenance contacted the facility fire alarm inspection and testing vendor. The vendor was directed to provide the testing of the magnetic fire/smoke barrier doors hold open devices and the magnetic delayed egress locks throughout the facility. The vendor will issue a complete inspection and testing report and then semi-annually thereafter. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance reviewed all vendor inspection and testing company reports related to the fire alarm system. No other deficiencies were identified. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. The Director of Maintenance will review all inspection and testing reports for compliance with 2010 NFPA 72: 72 National Fire Alarm and Signaling Code 14.2.5.5. The facility reviewed the Fire Alarm System Policy and updated it to include the testing of the magnetic fire/smoke barrier doors hold open devices and the magnetic delayed egress locks semi-annually. The policy also includes Documentation of all inspections, tests, and maintenance shall be maintained by the Maintenance Director. The Director of Maintenance or designee will utilize an audit tool to document the findings and report the audit findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI Committee on a monthly basis for 6 months, as well as correction plan if warranted.