HospitalInspections.org

NFPA 80 Standard for Fire Doors and Other Opening Protectives
4.2.1 Listed items shall be identified by a label.
4.2.2 Labels shall be applied in locations that are readily visible and convenient for identification by the AHJ after installation of the assembly.
4.2.3 The label or listing shall be considered evidence that sampling of such devices or materials have been evaluated by tests and that such devices or materials are produced under an in-plant, follow-up inspection programs.
5.2 Inspections
5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.
5.2.4 Swinging Doors with Builders Hardware of Fire Door Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of the door assembly.
5.2.4.2 As a minimum, the following items shall be verified.
(1) No open holes or breaks exist in the surface of the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self closing device is operational: that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Based on observations and interview, it was determined the facility failed to ensure two fire rated door assemblies could automatically close to a latched and secured position.

Findings include:

Observations during tour on 9/19/23 between 8:00 a.m. and 12:00 p.m. with Staff A (Senior Director of Facilities & Support Services) and Staff B (Facilities Supervisor) revealed the following two locations and existing conditions:
1. The 90-minute fire rated double door assembly, labeled #68-2, located on the lower level of the stairwell, failed to automatically close to a latched position when released from the magnetic hold-open device. The meeting edge gasket was preventing the full automatic closure.
2. The 45-minute fire rated door assembly, located on the upper level of the main kitchen stairwell, failed to automatically close to a latched position when released from the magnetic hold-open device. The top latching side of the door was binding against the frame preventing the full automatic closure.

Interview on 9/19/23 with Staff A and Staff B confirmed the above findings and existing conditions.

NFPA 12 A Standard on Halon 1301 Fire Extinguishing Systems (2009 edition)

Chapter 6 Inspection, Maintenance, Testing and Training
6.1.1 At least semiannually, all systems shall be thoroughly inspected, tested, and documented for proper operation by trained competent personnel. Tests shall be in accordance with the appropriate NFPA standards.
6.1.2 The documented report, with recommendations, shall be filed with the owner.
6.4 Enclosure Inspection. At least every 6 months the Halon protected enclosure shall be thoroughly inspected to determine if penetrations or other changes have occurred that could adversely affect Halon leakage.
6.4.1 Where the inspection indicates that conditions exist that could result in an inability to maintain the Halon concentration, they shall be corrected. If uncertainty still exists, the enclosure shall be retested for integrity.
6.5 Maintenance.
6.5.1 These systems shall be maintained in full operating condition at all times. Use, impairments, and restoration of this protection shall be reported promptly to the authority having jurisdiction.
6.5.2 Any troubles or impairments shall be corrected at once by competent personnel.
6.5.3 Any penetrations made through the Halon-protected enclosure shall be sealed immediately. The method of sealing shall restore the original fire resistance rating and tightness of the enclosure.
6.6 Training. All persons who could be expected to inspect, test, maintain, or decommission and remove fire extinguishing systems shall be thoroughly trained and kept thoroughly trained in the functions they are expected to perform.
6.6.1 Personnel working in a Halon-protected enclosure shall receive training regarding Halon safety issues.
6.7.2.2 Enclosure Integrity Acceptance. All total flooding systems shall have the enclosure examined and tested to locate and then effectively seal any air leaks that could result in a failure of the enclosure to hold the specified Halon 1301 concentration level for the specified holding period.

Based on observations and interview, it was determined the facility failed to ensure one Halon protected server room enclosure was maintained to have an airtight integrity, and failed to inspect, test, or maintain the enclosure on a semi-annual basis.

Findings include:

Observations during tour on 9/19/23 between 10:30 a.m. and 11:00 a.m. with Staff A (Senior Director of Facilities & Support Services) and Staff B (Facilities Supervisor) revealed the server room, a Halon protected enclosure, had several sections of the suspended ceiling removed or damaged, preventing an air tight enclosure. Additionally the last semi-annual inspection testing was conducted on 12/16/2022 for a total of over 10 months in between required semi-annual service's.

Interview on 9/19/23 with Staff A and Staff B confirmed the above findings, existing conditions, and location.

NFPA 13 Standard for the Installation of Sprinkler Systems

Chapter 8 Installation Requirements.
8.1.1 (1) Sprinklers shall be installed throughout the premises
8.6.5.1 Performance Objectives
8.6.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.6.5.2 and 8.6.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard.
8.10.6.3 Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard.
8.10.6.3.1 Continuous or non continuous obstructions that interrupt the water discharge in a horizontal plane more than 18" below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.10.6.3.
8.10.6.3.2 Sprinklers shall be installed under fixed obstructions over 4 feet wide such as stairs and landings.
8.10.6.3.3 Sprinklers shall not be required under obstructions that are not fixed in place.

Based on observations and interview, it was determined the facility failed to ensure one small storage closet was equipped with a sprinkler system coverage.

Findings include:

Observations during tour on 9/19/23 between 9:00 a.m. and 10:00 a.m. with Staff A (Senior Director of Facilities & Support Services) and Staff B (Facilities Supervisor) revealed one small storage closet, located on the second floor next to room #1100, had failed to be equipped with complete sprinkler system coverage.

Interview on 9/19/23 with Staff A and Staff B confirmed the above findings, location, and existing conditions.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
13.7 Fire Department Connections
13.7.1 Fire department connections shall be inspected quarterly to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper (s) is in place and operating properly.
(9) Interior of the connection is inspected for obstructions.
13.7.2 Components shall be repaired or replaced as necessary in accordance with the manufacturers instructions.
13.7.3 Any obstructions that are present shall be removed.
13.7.4 The piping from the fire department connection to the fire department check valve shall be hydrostatically tested at 150 psi for 2-hours at least once every 5 years.

Based on record review and interview, it was determined the facility failed to ensure three separate Fire Department Connections (FDC) received hydrostatic testing every five years.

Findings include:

Record review during tour on 9/19/23 between 9:30 a.m. and 12:00 p.m. with Staff A (Senior Director of Facilities & Support Services) and Staff B (Facilities Supervisor) revealed the sprinkler system vendor documentation failed to include any information on the current status of the FDC hydrostatic testing on the three separate sprinkler system riser connections.

Interview on 9/19/23 with Staff A, Staff B and the sprinkler system vendor, confirmed the available documentation and service.

NFPA 101 Life Safety Code (2012 edition)
8.5 Smoke Barriers
8.5.2.1 Smoke barriers required by this code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof.
8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
8.5.6.2 Penetrations for Cables. Cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall floor, or floor/ceiling assembly constructed as a smoke barrier, or a through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

Based on observations and interview, it was determined the facility failed to ensure three smoke barrier locations were maintained to resist the passage of smoke or the effects from fire.

Findings include:

Observations during tour on 9/19/23 between 1:00 p.m. and 2:30 p.m. with Staff A (Senior Director of Facilities & Support Services) and Staff B (Facilities Supervisor) revealed the following three smoke barrier locations with unprotected penetrations:
1. Above the suspended ceiling, over the smoke barrier doors outside the Computerized Tomography (CT) Scan room #213 had two unprotected penetrations from Flexible Metal Conduit (FMC) cables passing through the smoke barrier wall.
2. Above the suspended ceiling, inside the Phlebotomy room #2, had one unprotected penetration stuffed with rockwool insulation.
3. Above the suspended ceiling, inside the Physical Rehab Bay #3, had one unprotected penetration through the smoke barrier wall.

Interview on 9/19/23 with Staff A and Staff B confirmed the above findings, locations, and existing conditions.