Failure to Test Fire Alarm Interface Equipment
Penalty
Summary
The facility failed to test fire alarm interface equipment in accordance with NFPA 72, which could result in smoke detection devices failing to operate as designed, thereby endangering the occupants of the building. During a review of the facility's fire alarm inspection report, it was found that the report did not include complete results for the differential pressure testing of the duct smoke detectors. The report listed eight detectors in the system, but only four were reported as having been tested. Additionally, the report did not indicate that the sensitivity had been tested on any of the duct detectors. Further communication with the facility revealed that only five out of the eight detectors were tested, and there was still no indication that sensitivity tests were completed on any of the detectors. Differential pressure testing of tube-type duct detectors is a requirement of NFPA 72, and the failure to conduct these tests as required could compromise the safety of the building's occupants in the event of a fire.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1. What corrective actions will be accomplished for those residents found to have been affected by this deficient practice. On 04/10/25 differential pressure testing of the smoke detectors was completed. The report lists 8 detectors in the system and all 8 were tested. Sensitivity testing was completed on 04/21/2025 for the 8 duct detectors. No specific residents were affected by this alleged deficient practice. 2. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. No residents affected by the alleged deficient practice. On 04/21/25 the Maintenance Director/designee completed an audit of smoke detectors and duct detectors to ensure documentation in place for completion of biennial smoke detector sensitivity testing and annual duct detector differential testing; no other concerns identified. 3. What measures will be put into place or what systematic changes will you make to ensure that the deficient practice does not recur. The Maintenance Director was educated on 04/17/2025 related to maintaining documentation of the Fire Alarm System in accordance with National Fire Protection Association (NFPA) 101 by the Administrator. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. Random audits will be completed by the NHA/designee of smoke detectors and duct detectors to ensure documentation in place for completion of biennial smoke detector sensitivity testing and duct detector differential testing once a week for 4 weeks and then monthly for 2 months. Findings and audits will be reported to the QAPI committee for follow-up and recommendations monthly.