Failure to Maintain and Document Required Fire Alarm System Battery Testing
Penalty
Summary
The facility failed to maintain the Fire Alarm System (FAS) in accordance with NFPA 101, NFPA 70, and NFPA 72 requirements. During a tour, record review, and interview with the Maintenance Director, surveyors requested documentation of the annual Fire Alarm Control Panel (FACP) battery charger test and the 30-minute battery discharge test for the sealed lead-acid batteries. The facility provided annual and semiannual FAS testing records, but these did not include evidence that the required battery charger test or the 30-minute discharge test had been performed within the last 12 months. The Maintenance Director stated that he believed the vendor had performed the services but could not explain why the tests were not documented in the reports. The facility was given an opportunity to provide the missing records by email, but no additional documentation was received by the deadline. This deficiency affected all 120 residents in all four smoke compartments, as the required testing and documentation for the FACP batteries were not available for review as required by the applicable codes and standards.