Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
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Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0345
Based on document review, observation, and interview, it was determined the facility failed to ensure certified personnel completed repair work to the fire alarm panel, provide documentation of functional testing after repair to the fire alarm panel, and provide a record of completion after repair to the fire alarm panel, affecting the entire component.
Findings include:
1. Review of documentation on December 17, 2024, at 1:30 PM, revealed the fire alarm panel was in trouble for approximately two months and was observed to be in trouble at the time of the survey. The trouble was due to a power failure which was not battery related. Partial repairs had been attempted by non-certified personnel. No record of functional testing after work was completed was provided by the facility. No record of completion was provided by the facility.
Interview with the Administrator and Director of Maintenance on December 17, 2024, at 1:30 PM, confirmed the fire alarm was in trouble for a power failure for approximately two months, repairs had been attemped by non-certified personnel, no functional testing of the fire alarm panel had occurred after repairs were completed, and no record of completion was provided.
| | Plan of Correction - To be completed: 02/10/2025
1) The facility will have the fire panel inspected by certified personnel from Sciens Building Solutions to ensure completed repair work to the fire alarm panel is functional, Sciens Building Solutions will provide documentation of functional testing after repair certification to the fire alarm panel, and provide a record of completion of inspection of repair to the fire alarm panel.
2) Maintenance director and Administrator will be educated that all repairs to the fire panel must be completed by certified personnel.
3) Maintenance Director/Administrator will ensure certified repair personal work on fire panel and suppression system by auditing credentials of repair technician before any repairs are completed to fire safety system. Results of the audits will be reviewed at monthly QAPI for any trends and further recommendations.
4) Sciens Building Solutions will start inspection of fire control panel 01/10/2025. Corrective action will be completed by 02/10/2025
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