Failure to Inspect and Test Fire Service Backflow Tamper Switches
Penalty
Summary
The facility failed to maintain the automatic fire alarm system (AFAS) in accordance with NFPA 101 and NFPA 72 requirements. During a record review with the Facility Manager, it was discovered that there was no documentation of the required quarterly visual inspections and semi-annual testing of the fire service backflow tamper switches. These devices were not listed on any inspection or testing reports, indicating that they had not been included in the facility's regular fire alarm system maintenance program. During a facility tour, the tamper switches were observed to be installed on the fire service backflow device. In an interview, the Facility Manager acknowledged that they were unaware the devices were not being inspected or tested. The deficiency was identified through both documentation review and direct observation, confirming that the required maintenance and testing procedures for these components of the fire alarm system were not being followed.
Plan Of Correction
The facility Administrator/Designee contacted vendor to service the backflow tamper switches. The fire service backflow tamper switches were inspected and tested by a vendor company. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining the fire service backflow tamper switches in accordance with NFPA 101, which includes servicing and maintaining documentation of the fire service backflow tamper switches inspections. The Nursing Home Administrator/Designee will audit appropriate documentation of inspections conducted and quarterly documentation as it relates in accordance with NFPA 101. These audits will be conducted monthly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The facility Administrator/Designee contacted vendor to service the backflow tamper switches. The fire service backflow tamper switches were inspected and tested by a vendor company. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining the fire service backflow tamper switches in accordance with NFPA 101, which includes servicing and maintaining documentation of the fire service backflow tamper switches inspections. The Nursing Home Administrator/Designee will audit appropriate documentation of inspections conducted and quarterly documentation as it relates in accordance with NFPA 101. These audits will be conducted monthly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.