HospitalInspections.org

During Document Review it was noted that not enough Fire Drills were being held according to NFPA Standards.
The Findings Include:
On February 7, 2012, with Maintenance Staff, during Document Review at 9:30 A.M., it was noted that not enough Fire Drills were being held. Only (1) drill was held the 2nd and 4th Quarters of 2011. With the facility having (2) shifts, 2 drills per quarter are required. This could jeopardize Residents and Staff without proper knowledge of procedures. According to NFPA 101, (2000), 4.7.

4.7.1 Where Required. Emergency egress and relocation drills conforming to the provisions of this Code shall be conducted as specified by the provisions of Chapters 11 through 42, or by appropriate action of the authority having jurisdiction. Drills shall be designed in cooperation with the local authorities.
4.7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons
subject to the drill participate.
4.7.3 Competency. Responsibility for the planning and conduct of drills shall be assigned only to competent persons qualified to exercise leadership.
4.7.4 Orderly Evacuation. In the conduct of drills, emphasis shall be placed on orderly evacuation rather than on speed.
4.7.5* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
4.7.6 Relocation Area. Drill participants shall relocate to a predetermined location and remain at such location until a recall or dismissal signal is given.

During Document Review with Maintenance Staff it was noted there was no Sensitivity Report showing when Detectors had their last Sensitivity Testing and the Fire Alarm Panel was showing Trouble.
The Findings Include:
During the Document Review process on February 6, 2012, with Maintenance Staff, the facility was unable to substantiate that a biennial smoke detector sensitivity test with (2) Detectors showing as bad had been replaced, and why (2) Detectors had not been tested at all. Reference: NFPA 72 (1999 Edition) 7.3.2 " Sensitivity shall be checked within one year of installation. Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with, after the second required calibration test, if sensitivity tests indicate that the device(s) has maintained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if marked ), the length of time between calibration tests shall be permitted to extend to a maximum of five years."
7.3.2.1
The detectors shall be tested in place to ensure smoke entry into the sensing chamber
and an alarm response. Testing with smoke or listed aerosol approved by the
manufacturer shall be permitted as acceptable test methods. Other methods
approved by the manufacturer that ensure smoke entry into the sensing chamber
shall be permitted.
Any of the following tests shall be performed to ensure that each smoke detector is
within its listed and marked sensitivity range:
(a) Calibrated test method
(b) Manufacturer ' s calibrated sensitivity test instrument
(c) Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal
at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having
jurisdiction
The detector sensitivity shall not be tested or measured
using any device that administers an unmeasured concentration
of smoke or other aerosol into the detector.

Also, the Fire Alarm Panel at the Main Panel was showing that the System was in Trouble. This condition could jeopardize patients and Staff if one of the devices were not working. According to NFPA 72

During Document Review of the Sprinkler System there was nothing to indicate that a 5 year Internal Inspection had been completed.
The Findings Include:
During Document Review at 10:00A.M.. with Maintenance Staff, it was noted that there had been no 5 Year Internal Inspection done on the Sprinkler System. This condition could jeopardize the System with a build up of material to render the System inoperable. According to NFPA 25 (1999) 10-2.2* Obstruction Prevention. Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished
by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

During Document Review it was noted that the Kitchen Hood System was only getting a Annual Test which requires a Biannual Test.
The Findings Include:
On tour February 7, 2012, with Maintenance Staff, during Document Review, it was noted the Kitchen Hood was only getting an Annual Test, but Code requires the System to get a Biannual Test. According to NFPA 96, Chapter 4, "4.1.3.1 Maintenance and repairs shall be performed on all components at intervals necessary to maintain good working condition.
Inspection. An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

During tour of facility Kitchen with Maintenance Staff it was noted of Improper storage of Flammables in Kitchen area.
The Findings Include:
On tour February 7, 2012, with Maintenance Staff, at 11:00 A.M. it was noted in the Dietary kitchen Storage closet, there was storage of Flammable Sterno cans stored outside a Flammable Storage Cabinet. This condition could be hazardous to staff in case of a Fire Situation. Storage of Flammables and Liquid Gases shall be according to NFPA 101, 8.4.3, and NFPA 30.

On tour of facility February 7, 2012, it was noted in Electrical rooms there were various Electrical Panels with Breakers mis-labeled.
The Findings Include:
On tour February 7, 2012, with Maintenance Director, at 10:30 A.M. it was noted that in various Electrical Rooms there was Electrical Panels, that the Legend to identify Circuit Breakers was mis-labeled. Breakers labeled Spares were turned on to identify that the Breaker was being utilized. This condition could jeopardize residents and staff in a Fire/Smoke situation. According to NFPA 70, 408.4, "Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use...."

During Document Review it was noted that not enough Fire Drills were being held according to NFPA Standards.
The Findings Include:
On February 7, 2012, with Maintenance Staff, during Document Review at 9:30 A.M., it was noted that not enough Fire Drills were being held. Only (1) drill was held the 2nd and 4th Quarters of 2011. With the facility having (2) shifts, 2 drills per quarter are required. This could jeopardize Residents and Staff without proper knowledge of procedures. According to NFPA 101, (2000), 4.7.

4.7.1 Where Required. Emergency egress and relocation drills conforming to the provisions of this Code shall be conducted as specified by the provisions of Chapters 11 through 42, or by appropriate action of the authority having jurisdiction. Drills shall be designed in cooperation with the local authorities.
4.7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons
subject to the drill participate.
4.7.3 Competency. Responsibility for the planning and conduct of drills shall be assigned only to competent persons qualified to exercise leadership.
4.7.4 Orderly Evacuation. In the conduct of drills, emphasis shall be placed on orderly evacuation rather than on speed.
4.7.5* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
4.7.6 Relocation Area. Drill participants shall relocate to a predetermined location and remain at such location until a recall or dismissal signal is given.

During Document Review with Maintenance Staff it was noted there was no Sensitivity Report showing when Detectors had their last Sensitivity Testing and the Fire Alarm Panel was showing Trouble.
The Findings Include:
During the Document Review process on February 6, 2012, with Maintenance Staff, the facility was unable to substantiate that a biennial smoke detector sensitivity test with (2) Detectors showing as bad had been replaced, and why (2) Detectors had not been tested at all. Reference: NFPA 72 (1999 Edition) 7.3.2 " Sensitivity shall be checked within one year of installation. Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with, after the second required calibration test, if sensitivity tests indicate that the device(s) has maintained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if marked ), the length of time between calibration tests shall be permitted to extend to a maximum of five years."
7.3.2.1
The detectors shall be tested in place to ensure smoke entry into the sensing chamber
and an alarm response. Testing with smoke or listed aerosol approved by the
manufacturer shall be permitted as acceptable test methods. Other methods
approved by the manufacturer that ensure smoke entry into the sensing chamber
shall be permitted.
Any of the following tests shall be performed to ensure that each smoke detector is
within its listed and marked sensitivity range:
(a) Calibrated test method
(b) Manufacturer ' s calibrated sensitivity test instrument
(c) Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal
at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having
jurisdiction
The detector sensitivity shall not be tested or measured
using any device that administers an unmeasured concentration
of smoke or other aerosol into the detector.

Also, the Fire Alarm Panel at the Main Panel was showing that the System was in Trouble. This condition could jeopardize patients and Staff if one of the devices were not working. According to NFPA 72

During Document Review of the Sprinkler System there was nothing to indicate that a 5 year Internal Inspection had been completed.
The Findings Include:
During Document Review at 10:00A.M.. with Maintenance Staff, it was noted that there had been no 5 Year Internal Inspection done on the Sprinkler System. This condition could jeopardize the System with a build up of material to render the System inoperable. According to NFPA 25 (1999) 10-2.2* Obstruction Prevention. Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished
by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

During Document Review it was noted that the Kitchen Hood System was only getting a Annual Test which requires a Biannual Test.
The Findings Include:
On tour February 7, 2012, with Maintenance Staff, during Document Review, it was noted the Kitchen Hood was only getting an Annual Test, but Code requires the System to get a Biannual Test. According to NFPA 96, Chapter 4, "4.1.3.1 Maintenance and repairs shall be performed on all components at intervals necessary to maintain good working condition.
Inspection. An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

During tour of facility Kitchen with Maintenance Staff it was noted of Improper storage of Flammables in Kitchen area.
The Findings Include:
On tour February 7, 2012, with Maintenance Staff, at 11:00 A.M. it was noted in the Dietary kitchen Storage closet, there was storage of Flammable Sterno cans stored outside a Flammable Storage Cabinet. This condition could be hazardous to staff in case of a Fire Situation. Storage of Flammables and Liquid Gases shall be according to NFPA 101, 8.4.3, and NFPA 30.

On tour of facility February 7, 2012, it was noted in Electrical rooms there were various Electrical Panels with Breakers mis-labeled.
The Findings Include:
On tour February 7, 2012, with Maintenance Director, at 10:30 A.M. it was noted that in various Electrical Rooms there was Electrical Panels, that the Legend to identify Circuit Breakers was mis-labeled. Breakers labeled Spares were turned on to identify that the Breaker was being utilized. This condition could jeopardize residents and staff in a Fire/Smoke situation. According to NFPA 70, 408.4, "Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use...."