Failure to Conduct Required Smoke Damper Testing in HVAC System
Penalty
Summary
The facility failed to maintain its HVAC system in accordance with regulatory requirements, specifically by not conducting the required four-year inspection and testing of the fire/smoke dampers. During a document review and interview with staff, it was found that the last smoke damper testing was conducted on 9/28/20, and no subsequent testing had been performed as required. The facility was unable to provide current inspection and testing records for the smoke dampers. Staff indicated that damper testing for the Skilled Nursing Building was assumed to follow the same schedule as the Main Hospital Building, leading to the oversight. This deficiency affected all 43 residents and both smoke compartments in the facility, as the required periodic inspection and testing of fire/smoke dampers had not been completed.
Plan Of Correction
The last smoke damper inspection was completed on September 28, 2020, exceeding the four-year testing requirement. On April 15, 2025, the facility contacted the licensed HVAC inspection company to inspect and test all fire/smoke dampers within Building 02. The inspection and testing are scheduled on May 5th, 2025, by the vendor. The Maintenance Department Staff were educated on the regulatory differences between hospital and SNF buildings to prevent recurrence. A digital calendar reminder and compliance tracker were implemented to ensure timely testing in 2029. The maintenance lead will be responsible for contacting and scheduling the timely inspections with the vendor.