Failure to Document Fire Alarm System Inspections and Testing
Penalty
Summary
The facility failed to provide documentation verifying that required semi-annual inspections and annual testing of the fire alarm system had been performed within the previous twelve months. During a document review, surveyors were unable to locate records confirming that these inspections and tests had occurred as mandated by NFPA 70 and NFPA 72 standards. This lack of documentation was confirmed in an interview with the Director of Nursing and the Director of Maintenance, who acknowledged that the records for the semi-annual inspection and annual testing of the fire alarm system were not available.
Plan Of Correction
The facility has received documentation of the semi-annual and annual tests of the fire alarm system. The facility will ensure that all verifying documentation is received and on premises of any inspections that are completed. The Environmental Services Director has been re-educated on the requirements of regulation K0345. The NHA or designee will complete an annual audit of the tests of the fire alarm system in July x 2 years. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.