Lack of Documentation and Final Inspection for Newly Installed Boiler
Penalty
Summary
The facility failed to ensure that its heating, ventilation, and air conditioning (HVAC) system was in compliance with regulatory requirements, specifically section 9.2. During an observation, it was found that a newly installed boiler heating unit lacked manufacturer information and proof of a State of Michigan boiler inspection. The office manager was unable to confirm whether the necessary corrections identified by the state boiler inspector during a previous visit had been completed, and only had limited information about the inspector. Further confirmation from the State of Michigan boiler inspector indicated that the required corrections on the new boiler installation had not yet been completed, and a final inspection had not been requested.
Plan Of Correction
Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: The boiler was inspected and did not pass. Contractor has made the required repairs and is calling to schedule another inspection as soon as possible. Once the state boiler inspection has been completed, the local building department will perform their inspection. I personally spoke with the state boiler inspector on Friday, as the contractor is not fulfilling his responsibilities of completing this project and scheduling the inspection. The inspector said he would be able to come on Monday, June 30 or July 1, but I have not heard back with a confirmed date or time. I am unable to force the contractor or inspector to get this taken care of in a timely manner, so I do not have firm dates that it will be inspected or approved. Address how the facility will identify other residents having a potential to be affected by the same deficient practice: The residents are not affected by this deficient practice. The boiler is not in use as it is not heating season and operates as designed when needed. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not reoccur: This contractor will not be used again in the future. Maintenance Director will ensure any future contractors will complete permits and inspections prior to being paid in the future. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Maintenance director will monitor weekly and maintain communication with contractor to ensure the inspections are completed. Will be discussed at quarterly QAPI meetings.