Bringing transparency to federal inspections
Tag No.: K0345
Based on record review and interview, the facility failed to ensure installed fire alarm/smoke detection systems were inspected and/or tested in accordance with NFPA 72. Failure to ensure fire alarm and smoke detection systems are inspected and tested in accordance with the standard, has the potential to hinder system and staff response during a fire event. This deficient practice affected 16 patients, staff and visitors on the date of the survey.
Findings include:
During review of provided system inspection records conducted on June 25, 2024 from 8:30 am - 11:30 am, the facility failed to provide documentation for (1) location of all devices tested including but not limited to pull stations, horn strobes, smoke detectors and heat detectors. (2) smoke detection sensitivity testing within the previous five years. When asked at 11:00 am the maintenance director stated all smoke detectors were replaced in April of 2022 with no further testing of sensitivity.
Actual NFPA standard:
NFPA 72
14.4 Testing.
14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.
14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for 1 year thereafter.
14.6.2.4% A record of all inspections, testing, and maintenance shall be provided that inc