HospitalInspections.org

Based on record review and interview staff it was determined the facility failed to provide documentation of a local fire inspection. An annual local fire inspection ensures the building remains within the building codes and fire safety codes. Failure to have an annual fire inspection could bring harm to patients and staff during an emergency.

CMS State Operations Manuel Appendix A- Interpretive Guidelines §482.11 The hospital must ensure that all applicable Federal, State and local law requirements are met.. The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. NFPA 101 2012 Life Safety Code Section 4.6.12. Maintenance, Inspection, and Testing. 4.6.12 Maintenance, inspection and testing shall be performed under supervision of a responsible person who shall ensure that testing, inspection, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.


Findings include:

Records review on Sep 29, 2021 revealed the facility failed to provide required documentation of an annual local fire inspection.

Employees #4 and #6 acknowledged during the exit conference that the facility failed to provide required documentation of an annual local fire inspection.

Based on record review and interview it was determined that the facility failed to provide documentation of the Monthly, quarterly inspector test and simi annual main drain test of the automatic sprinkler system. Failing to maintain the sprinkler system will cause harm to patients and staff during a fire if the sprinkler system does not activate as designed.

NFPA 101 Life Safety Code, 2012 edition, Chapter 21, "Existing Ambulatory Health Care Occupancies," Section 21.1.1.1.3 "The provisions of Chapter 4, General, shall apply."
Chapter 4, Section 4.6.12.4, "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. NFPA 13, "Installation of Sprinkler Systems." Chapter 26, Section 26.1, General, "A sprinkler system installed in accordance with this standard shall be properly inspected, tested and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Chapter 5 Sprinkler Systems. This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. 5.2.4 Gauges. 5.2.4.1 * Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.3.3 Waterflow Alarm Devices. 5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 * Vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.


Chapter 13, Main Drain Test Section 13.2.5.1 "In systems where the sole water supply is through a backflow preventer and or pressure reducing valves, the main drain test of at least one system downstream of the device shall be conducted on a quarterly basis

Chapter 14, Section 14.2 "Internal Inspection of Piping" "Except as discussed in 14.2.1.1 and 14.2.1.4 and inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspection for the presence of foreign organic and inorganic material."

Chapter 5, Section 5.3.1.1.1.3 * Sprinklers manufactured using fast-response elements that have been in service for 20 years shall be replaced, or representative samples shall be tested and then retested at 10-year intervals.


Findings include:

Records review and interview on Sept 28, 2021 revealed the facility did not maintain written records of Monthly, quarterly or simi-annual testing of the facilities sprinkler system in accordance with NFPA 25 requirements.

Employees #4 and #6 acknowledged during the exit conference that the facility did not maintain written records of quarterly or simi-annual testing of the facilities sprinkler system.