Missing Documentation for Fire Alarm System Testing
Penalty
Summary
The facility failed to maintain proper documentation for the fire alarm system's semi-annual testing as required by NFPA 70 and NFPA 72. During a document review, surveyors were unable to locate records demonstrating that the semi-annual fire alarm testing had been completed. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the required documentation. No information regarding residents or their medical conditions was included in the report, and the deficiency pertains solely to the facility's failure to provide evidence of required fire alarm system testing.
Plan Of Correction
The visual inspection of the fire alarm was completed. Maintenance director/designee will monitor fire alarm visual inspections are completed timely with proper documentation by using the TELS PM program. Weekly visual inspection of fire alarms will be conducted for 4 weeks, and then monthly for 2 months. Results are documented and placed in the Life Safety binder. Findings will be reported to the QI committee quarterly.