Failure to Conduct Semi-Annual Kitchen Hood Fire Suppression Inspections
Penalty
Summary
The facility failed to ensure that cooking facilities were protected in accordance with NFPA 96 and NFPA 17A standards. Specifically, there was an 11-month gap between service inspections of the kitchen hood fire suppression system, as evidenced by inspection reports dated 1/2/24 and 12/2/24 from two different vendors. NFPA 17A 7.3.3 requires that hood fire suppression system inspections be conducted semi-annually. This deficiency was confirmed during interviews with two maintenance staff members at the time of observation. No information regarding specific patients, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Element 1 - The Environmental Services Director was able to locate the inspection report from Summit Fire Protection conducted on 6/28/24 to comply with semi-annual kitchen hood fire suppression inspections. The reviewed indicated dates are 1/2/24 and 12/2/24. Element 2 - The Environmental Services Director placed the inspection report for the semi-annual kitchen hood suppression system with other inspection reports to verify compliance. Element 3 - The Environmental Services Director or designee will audit report documentation annually and follow up on inspection reports from outside vendors with a recurring work order to ensure compliance with NFPA 96. Element 4 - The Environmental Services Director or designee will report audit findings to the Quality Assurance Performance Improvement (QAPI) Committee annually, with further monitoring per QAPI recommendations. Any identified issues will trigger retraining and/or corrective action. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.