Deficient Fire Alarm System Testing and Maintenance Documentation
Penalty
Summary
The facility failed to ensure that the fire alarm system was installed, tested, and maintained in accordance with Life Safety Code (LSC) Section 19.3.4.1, 9.6, and NFPA 72. During a review of facility records, it was found that documentation for the testing of fire alarm devices did not include individual device testing by location with a minimum pass or fail result, as required by NFPA 14.6.2.4(7). Additionally, there was no current documentation for the required bi-annual smoke detector sensitivity testing, with the last record dated 12/30/2022, which does not meet the requirements of NFPA 72 14.4.5.3. These findings were confirmed during an interview with a maintenance staff member at the time of the records review.
Plan Of Correction
Element #1: Fire alarm devices have been recorded and tested by location to at a minimum of pass or fail by 07/09/2025 by Boynton Fire Safety Service. Bi-annual smoke detector sensitivity testing has been completed on 07/09/2025 by Boynton Fire Safety Service. Element #2: This deficient practice could potentially affect all occupants in the event of failure to the fire alarm system. Ensure fire alarm system is tested and maintenance in accordance with LSC Section 19.3.4.1, 9.6 and NFPA 72. Element #3: Nursing Home Administrator/designee has completed re-education with the Environmental Services Director on Fire Alarm System policy by the completion date. Element #4: Environmental Services Director/designee will complete audits to ensure that Fire alarm devices have been recorded and tested by location to at a minimum of pass or fail and the smoke detector sensitivity testing gets completed as required. Audits will be completed weekly for four weeks and then monthly thereafter until substantial compliance has been sustained. Results of the audits will be reported to facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved.