HospitalInspections.org

Based on staff interview and record review, facility staff failed to inspect the wet sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 0.

Record review on 9/25/19 did not show the following inspections:


-5 year internal pipe inspection.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.

Based on observation and facility staff interview, the facility staff failed to provide a remote annunciator panel (a panel providing information on the condition and problems with the emergency generator) for one of one emergency generators at a constantly attended location. The census was 0.

1. Observation on 9/25/2019 during the facility tour, did not show a remote annunciator panel for the emergency generator in a constantly attended location.


During an interview on 9/25/2019 at 11:47 A.M., the Director of Plant Operations confirmed the observation.

NFPA 99, 2012 edition, section 6.4.1.1.17 states:

"6.4.1.1.17 Alarm Annunciator. A remote annunciator that is
storage battery powered shall be provided to operate outside of
the generating room in a location readily observed by operating
personnel at a regular work station (see 700.12 of NFPA 70, National
Electrical Code). The annunciator shall be hard-wired to indicate
alarm conditions of the emergency or auxiliary power
source as follows:
(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating
to supply power to load
(b) When the battery charger is malfunctioning
(2) Individual visual signals plus a common audible signal to
warn of an engine-generator alarm condition shall indicate
the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in
6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains
less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

6.4.1.1.17.1* A remote, common audible alarm shall be provided
as specified in 6.4.1.1.17.4 that is powered by the storage
battery and located outside of the EPS service room at a work
site observable by personnel. [110:5.6.6]

6.4.1.1.17.2 An alarm-silencing means shall be provided, and
the panel shall include repetitive alarm circuitry so that, after
the audible alarm has been silenced, it reactivates after the
fault condition has been cleared and has to be restored to its
normal position to be silenced again. [110:5.6.6.1]

6.4.1.1.17.3 In lieu of the requirement of 5.6.6.1 of NFPA110, a
manual alarm-silencing means shall be permitted that silences
the audible alarm after the occurrence of the alarm condition,
provided such means do not inhibit any subsequent alarms from
sounding the audible alarm again without further manual action.
[110:5.6.6.2]

6.4.1.1.17.4 Individual alarm indication to annunciate any of
the conditions listed in Table 6.4.1.1.16.2 shall have the following
characteristics:
(1) It shall be battery powered.
(2) It shall be visually indicated.
(3) It shall have additional contacts or circuits for a common
audible alarm that signals locally and remotely when any
of the itemized conditions occurs.
(4) It shall have a lamp test switch(es) to test the operation of
all alarm lamps.

6.4.1.1.17.5 Acentralized computer system (e.g., building automation
system) shall not be permitted to be substituted for
the alarm annunciator in 6.4.1.1.17 but shall be permitted to
be used to supplement the alarm annunciator.

6.4.1.2 Battery. Battery systems shall meet all requirements of
Article 700 of NFPA 70, National Electrical Code.


Table 6.4.1.1.16.2 Safety Indications and Shutdowns
Level 1
Indicator Function (at Battery Voltage) CV S RA
(a) Overcrank X X X
(b) Low water temperature X - X
(c) High engine temperature pre-alarm X - X
(d) High engine temperature X X X
(e) Low lube oil pressure pre-alarm X - X
(f) Low lube oil pressure X X X
(g) Overspeed X X X
(h) Low fuel main tank X - X
(i) Low coolant level X O X
(j) EPS supplying load X - -
(k) Control switch not in automatic
position
X - X
(l) High battery voltage X - -
(m) Low cranking voltage X - X
(n) Low voltage in battery X - -
(o) Battery charger ac failure X - -
(p) Lamp test X - -
(q) Contacts for local and remote
common alarm
X - X
(r) Audible alarm-silencing switch - - X
(s) Low starting air pressure X - -
(t) Low starting hydraulic pressure X - -
(u) Air shutdown damper when used X X X
(v) Remote emergency stop - X -
CV: Control panel-mounted visual. S: Shutdown of EPS indication.
RA: Remote audible. X: Required. O: Optional.
Notes:
(1) Item (p) shall be provided, but a separate remote audible signal shall
not be required when the regular work site in 5.6.6 of NFPA110, Standard
for Emergency and Standby Power Systems, is staffed 24 hours a day.
(2) Item (b) is not required for combustion turbines.
(3) Item (r) or (s) is required only where used as a starting method.
(4) Item (j): EPS ac ammeter shall be permitted for this function.
(5) All required CV functions shall be visually annunciated by a remote,
common visual indicator.
(6) All required functions indicated in the RAcolumn shall be annunciated
by a remote, common audible alarm as required in 5.6.5.2(4) of
NFPA 110.
(7) Item (i) requires a low gas pressure alarm on gaseous systems.
(8) Item (b) must be set at 11°C (20°F) below the regulated temperature
determined by the EPS manufacturer, as required in 5.3.1 of
NFPA 110."