Failure to Maintain Annual Fire Alarm System Testing
Penalty
Summary
The facility failed to maintain annual testing of the fire alarm system, specifically the annual duct detector differential testing. During a record review, surveyors found that the most recent documented testing was completed nearly a year prior, and no evidence was provided to show that the required annual testing had been performed since then. The Assistant Director of Facilities was present during the review and acknowledged the deficiency. This finding was confirmed during the exit conference with both the Administrator and the Assistant Director of Facilities. The lack of current documentation for the annual duct detector differential testing was the sole focus of the deficiency, and no additional patient or resident details were provided in the report.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: All residents have the potential to be affected by this deficient practice; however, a specific individual was not identified in this deficiency. On 3/12/25, duct detector differential testing was completed. Any identified problems were immediately corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct the annual duct detector differential testing. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents have the potential to be affected by this practice. On 3/12/25, duct detector differential testing was completed. Any identified problems were immediately corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct the annual duct detector differential testing. C) What measures will be put in place or what system change will be made to ensure this will not recur: On 3/12/25, duct detector differential testing was completed. Any identified problems were immediately corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct the annual duct detector differential testing. The Administrator Consultant developed a tracking schedule for the completion of the testing of the duct detector differential. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director on the tracking schedule. The schedule notes the dates on which the Maintenance Director is to have the annual duct detector differential completed. The Maintenance Director is to provide documentation to the Administrator of the date of the testing. Upon completion of the testing, the Maintenance Director is to provide a copy of the report to the Administrator. D) How the corrective action will be monitored to ensure the potential will not occur: The Maintenance Director, or designee, will report the findings of the annual duct detector differential testing to the QA and QAPI committee monthly for 12 months.