Incomplete Fire Alarm Sensitivity Testing Documentation
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with NFPA 70 and NFPA 72 standards. During a record review, it was found that the fire alarm sensitivity testing report only included the range of values for smoke detectors tested, rather than providing the required individual values for all smoke detectors within the facility. This incomplete documentation was confirmed during an interview with the Maintenance Director at the time of the survey observation.
Plan Of Correction
The correct bi-annual fire alarm sensitivity report was obtained on 5-6-25. The report was dated 11-27-24 and contains the correct documentation showing sensitivity values for each device. A one-time audit was completed on all fire alarm documentation by the Maintenance Director on 5-7-25 to ensure all inspections contain the correct information. Education was provided to the Maintenance Director on 5-20-25 as to the requirements of the 2-year sensitivity testing report, ensuring that they show the correct values for each device. A monthly audit x3 will be completed by the Maintenance Director or designee to ensure all fire alarm documentation contains the correct information. Audit findings will be presented to the facility QAPI committee and will only be discontinued with substantial compliance and with approval of the facility QAPI. The Administrator is responsible for achieving and sustaining compliance.