Fire Alarm System Altered Without Required Plan Approval or Inspection
Penalty
Summary
The facility failed to obtain required plan approval and conduct an occupancy survey before making changes to its fire alarm system. Specifically, carbon monoxide detectors were installed on the existing fire alarm system without prior plan review or approval from the Department of Health. No documentation was provided to show that the necessary approvals were sought or granted before these modifications were made. Additionally, the facility placed the altered fire alarm system into service without completing an occupancy inspection or providing a record of completion for the changes. Interviews with the Director of Nursing and Director of Maintenance confirmed that the fire alarm system was altered and put into use without the required approval from the Pennsylvania Department of Health.
Plan Of Correction
K 0341 1. The facility cannot retroactively correct. 2. All new plans related to the fire alarm system will undergo both a formal plan review and an occupancy survey prior to implementation. 3. The Environmental Services Director has been re-educated on the requirements of regulation K0341. 4. The Nursing Home Administrator (NHA) or their designee will review all proposed changes to the fire alarm system to ensure full compliance with applicable codes and regulations.