Failure to Maintain Required Elevator Firefighter's Service Testing Records
Summary
The facility failed to ensure that elevators were inspected and tested according to the required standards, specifically ASME A17.1 and ASME/ANSI A17.3, including the monthly operation and documentation of the firefighter's service. During a record review, surveyors found that there was no written record of the monthly firefighter's service tests for the elevators. When questioned, the Maintenance Director stated that this was the first time they had heard about the requirement, and no documentation was available at the time of the survey exit. These findings were confirmed by both the Director of Maintenance and Security and the Maintenance Director during the review and interview. This deficiency could potentially affect all 39 residents in the event of an emergency, as the required elevator safety checks and documentation were not maintained.
Penalty
The facility failed to maintain proper emergency communication systems in two of its four elevators. During testing, the emergency phones in elevators #1 and #2 malfunctioned, disconnecting calls prematurely and lacking pre-recorded messages. This issue had the potential to impact the safety of 88 residents.
Elevator Emergency Communication Deficiency
Penalty
Summary
The facility failed to maintain emergency communications in proper working condition for two of the four elevators tested, as observed during a survey conducted on December 5, 2024, and December 9, 2024. During the inspection, it was found that the emergency communication telephones in elevators #1 and #2 were not functioning correctly. In elevator #1, when the emergency communication button was pressed, the operator answered, but no words were exchanged, and the call disconnected automatically within approximately 20 seconds. A second test confirmed that the phone did not function properly, as it lacked a pre-recorded message. Similarly, in elevator #2, the emergency communication phone also malfunctioned. When tested, the operator answered and requested the caller to hold, but the call disconnected automatically within approximately 20 seconds. These deficiencies were confirmed by the facility's representative during the observations and were reported during the Life Safety Code survey exit. The malfunctioning emergency communication systems in these elevators had the potential to affect the safety of 88 residents in the facility.
Plan Of Correction
The facility must ensure that all elevator systems, including emergency communication devices (e.g., emergency phones in elevators), are properly maintained and functioning to ensure the safety and well-being of residents and staff. **Immediate Corrective Action:** **Inspection of All Elevators:** An immediate inspection of all elevator emergency communication systems (phones) was conducted to assess functionality. This inspection was performed by the facility's maintenance team and qualified elevator service provider to ensure that all emergency phones are working. The inspection focused on: - Ensuring each emergency phone connects to a 24-hour monitoring service or can directly communicate with emergency personnel. - Verifying that phones are in working condition with clear audio and uninterrupted functionality. **Immediate Repair or Replacement:** Any non-functional or damaged emergency phones was repaired or replaced immediately to ensure they met operational requirements. All phones that are out of service will be marked as "out of order" until repaired and will not be used until fully functional. **Test All Emergency Phones:** Once repairs or replacements were made, each elevator emergency phone was tested for connectivity to emergency services, ensuring they work properly in the event of an emergency. **Systematic Changes to Prevent Recurrence:** **Scheduled Inspections and Preventive Maintenance:** A monthly inspection will be established for all elevator emergency phones. The inspection will include: - Functionality testing to ensure clear, immediate communication with emergency personnel. - Visual inspection to check for physical damage or wear. These inspections will be documented, and the results will be reviewed by the Maintenance Director. **Documentation and Record-Keeping:** A logbook will be created and maintained to record each inspection and test result, including: - Date and time of inspection. - Description of any identified issues. - Actions taken (repair, replacement, etc.). - Confirmation that repairs have been completed and phones are operational. **Training of Maintenance Staff:** Maintenance personnel will receive training on the proper testing and repair of elevator emergency phones, including how to ensure they are properly connected to emergency services. **Follow-Up Monitoring and Compliance:** **Ongoing Monitoring:** To ensure long-term compliance, the monthly inspection schedule will be adhered to and documented. **Responsible Parties:** Maintenance Director: Responsible for overseeing the inspection, repair, and maintenance of all elevator emergency communication systems. Oversees all safety systems, including elevator emergency phones, ensuring compliance with fire safety codes. **Completion Date for Corrective Action:** All immediate corrective actions, including repairs and testing of emergency phones, was completed. Monthly inspections and preventive maintenance will commence immediately after the corrective actions have been implemented and will continue regularly. The results of the inspections will be discussed at the quarterly safety committee meetings.
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