Failure to Maintain Fire Hose Inspection Compliance
Summary
The facility failed to ensure that all fire hoses were inspected, tested, and maintained in accordance with the 2011 NFPA 25 standards. During a life safety survey, it was observed that the fire hoses located on landings 1-4 of stairwell E were marked with a date of March 2018, indicating that they had not been inspected or replaced within the required five-year period. This deficiency was identified through both observation and staff interviews, where the Director of Maintenance acknowledged the oversight and indicated that a vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrective Action 1. The Director of Maintenance engaged our Service Company to replace the identified standpipe hoses with new hoses in all locations more than five years old. 2. The Director of Maintenance engaged our Service Company to inspect the buildings standpipe system to determine hose testing years and complete NFPA required testing if necessary. II. Identification of Other Residents All Residents have the potential to be affected by this practice. The Director of Maintenance had the company check all hose stations and for similar issues. No other deficiencies were found. No other standpipe, hose or water-based fire prevention issues were found. III. Systemic Changes 1. The Administrator policy on Environmental Rounds was reviewed and revised by Administration to include the auditing and monitoring of standpipe hose system. 2. The existing rounds inspection form has added the monthly standpipe audit tool. 3. All environment of care staff were educated on the revision of this policy by the Director of Maintenance. Non-compliant hose systems shall be replaced with appropriate type and reported to the Administrator and Director of Maintenance for scheduled correction. 4. This has been added to the facility preventive Engineering program. 5. Staff involved in the sprinkler system were educated by the Director of Maintenance that any issues with standpipe system identified during rounds will be corrected asap and interim safety measures put in place as needed until repairs are complete. IV. QA Monitoring An audit tool was created by the Director of Maintenance to monitor compliance with required inspections of sprinkler systems. This audit includes inspection of hose racks. Any identified issues will be scheduled for correction asap. All of the facilities plenum will be audited monthly by the Director of Maintenance for the first 3 months and then quarterly for 9 months. Audit results shall be reported to QAPI Committee quarterly to review with the team to ensure that repairs are being performed. Frequency of ongoing audits will be determined by the Committee based on audit results once 100% compliance is achieved. V. Title Responsible Director of Maintenance
Penalty
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