Fire Alarm System Out of Service Without Proper Protocols
Summary
The facility failed to meet the requirements of NFPA 101 regarding the fire alarm system. Specifically, the fire alarm system was out of service for more than four hours within a 24-hour period. During this time, the facility did not notify the authority having jurisdiction, nor did they evacuate the building or provide an approved fire watch for the safety of all parties left unprotected by the shutdown. This deficiency was identified based on document review and interviews, indicating a lack of required policies affecting the entire facility.
Plan Of Correction
Facility will maintain a fire watch policy and update in EP book. The Director of Maintenance will audit EP book for updated policies 2x weekly for 2 months. All findings will be brought to QAPI for review.
Penalty
A deficiency was identified when the facility did not have a fire watch policy in place for periods when the fire alarm system was out of service for more than four hours. This was confirmed through document review and interviews with the DON and Director of Maintenance.
Surveyors found that the facility did not have a required fire watch policy in place for situations when the fire alarm system is out of service for more than four hours in a 24-hour period. This was confirmed through document review and interviews with the Maintenance Supervisor and Director of Safety/Security.
A review of facility records and staff interviews revealed that the fire watch policy did not specify that a fire watch would be implemented within four hours of the fire alarm system being out of service, as required. This omission affected all residents in the facility.
Lack of Fire Watch Policy During Fire Alarm System Outage
Penalty
Summary
The facility failed to maintain a full and accurate fire watch policy for situations when the fire alarm system is out of service for more than four hours, as required by NFPA 101. During a document review, it was found that there was no fire watch policy in place to address the impairment or outage of the fire alarm system for extended periods. This deficiency was confirmed during interviews with the Director of Nursing and the Director of Maintenance, who acknowledged the absence of such a policy. The lack of a fire watch policy affected the entire component of the fire alarm system and was identified through both documentation review and staff interviews. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
The facility has a Fire Watch Policy that is available for review. The Fire Watch Policy will be placed in the Safety and Disaster Policy & Procedure Manual. The Environmental Services Director will be educated on the Fire Watch Policy. The Safety and Disaster Policy & Procedure Manual will be reviewed yearly, every July.
Missing Fire Watch Policy During Fire Alarm Outage
Penalty
Summary
The facility failed to maintain required policies for the fire alarm system, specifically lacking a fire watch policy to implement in the event the fire alarm system was out of service for more than four hours in a 24-hour period. During a document review, it was found that there was no such policy available, which is necessary to ensure safety when the fire alarm system is not operational. This finding was confirmed during an interview with the Maintenance Supervisor and Director of Safety/Security.
Plan Of Correction
Fire watch policy in place. Facility will ensure policy is available for survey team during all inspections.
Incomplete Fire Watch Policy During Fire Alarm System Outage
Penalty
Summary
The facility failed to maintain compliance with fire safety regulations by not having a complete fire watch policy in place. During a record review and interview, it was found that the facility's fire watch policy did not specify that a fire watch would be implemented after no more than four hours of the fire alarm system being out of service, as required. Staff confirmed that the policy lacked a defined time frame for initiating a fire watch. This deficiency affected all 90 residents across ten smoke compartments.
Plan Of Correction
The facility recognizes the importance of maintaining the fire alarm system. The facility shall continue to maintain the fire alarm system, and shall update the fire watch policy. When the fire alarm system is "out of service," the facility's fire watch policy shall include language stating, "fire watch will be implemented after no more than four hours of the fire alarm system being out of service." The updated Fire Watch Policy will be reviewed, updated, and adopted June 26, 2025, during the QA Committee meeting. Further issues regarding the fire alarm system fire watch policy shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, DON, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance.
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