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NFPA 101, Life Safety Code, 2000 Edition
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.

19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

Based on record review and interview, the facility failed to maintain evacuation plans. This was evidenced by outdated evacuation plans posted throughout the building. This had the potential to delay evacuation during an emergency, and affected the entire facility at St. Helena Hospital.

Findings:

During a tour of the facility with the Facilities Manager, the disaster manual and evacuation plans were reviewed.

St. Helena Hospital:
On 7/11/12, at 10:36 a.m. the evacuation plans posted throughout the facility included an exit that was no longer available by the Emergency Department. The Facilities Manager stated that the exit that was once available by the Emergency Department was undergoing construction, and the exit was no longer available for evacuation.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.2 Emergency Forces Notification. Fire department notification shall be accomplished in accordance with 9.6.4.

9.6.4 Emergency Forces Notification. Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency. Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm Code:
(1) Auxiliary alarm system
(2) Central station connection
(3) Proprietary system
(4) Remote station connection

NFPA 72, National Fire Alarm Code, 1999 Edition
5-3.4.7 The maximum elapsed time from sensing a fire alarm at an initiating device or initiating device circuit until it is recorded or displayed at the proprietary supervising station shall not exceed 90 seconds.

7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.

7-3.2* Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.

Based on observation, interview and record review, the facility failed to maintain their fire alarm system in accordance with NFPA, and NFPA 72. This was evidenced by no current annual fire alarm report available for review, and by no evidence that fire alarm devices had reported to a central monitoring station. This affected the entire facility at St. Helena Cardiology Outpatient Services, and the entire facility at Rehab Outpatient Services. This had the potential to delay the response of fire emergency personnel, increasing the risk of injury to patients, visitors, and staff.

Findings:

During a tour of the facility with the Facilities Manager, the fire alarm system was tested, observed, and records were reviewed.

St. Helena Cardiology Outpatient Services:
1. On 7/12/12, at 8:15 a.m., the annual fire alarm inspection report was requested for St. Helena Cardiology Outpatient Services. The Facilities Manager stated that no current annual fire alarm system testing had been done at the facility.

2. On 7/12/12, at 8:30 a.m., the activity report from the facility's central monitoring station had been requested for all the fire alarm devices activated from 7:30 a.m., to 8:00 a.m., at St. Helena Cardiology Outpatient Services. The Director of Quality/Infection Prevention stated that current issues with the monitoring company prevented them from obtaining an activity report for the fire alarm devices activated on 7/12/12.

Rehab Outpatient Services:
3. On 7/12/12, at 11:30 a.m., the annual fire alarm inspection report was requested for Rehab Outpatient Services. The Facilities Manager stated that no current annual fire alarm system testing had been done at the facility.

NFPA 101, Life Safety Code, 2000 Edition
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, waterflow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by tamper switches that failed to send signals to the central monitoring company and to the Fire Control Panel, no quarterly inspection of the sprinkler system, inspection reports not available for review, and by sprinkler heads with debris. This deficient practice affected all patients, staff, and visitors in the St. Helena Cardiology Outpatient Services, and this affected 1 of 5 Smoke Compartments in St. Helena Hospital. This could result in the failure of the sprinkler system in the event of a fire.

Findings:

During a tour of the facility with the Facilities Manager, the sprinkler system was tested and observed, and records were reviewed.

St. Helena Hospital:
1. On 7/11/12, at 10:33 a.m., the sprinkler head located outside the building by Room 212 was covered with an accumulation of debris.

2. On 7/11/12, at 10:40 a.m., the sprinkler head located in the storage room by the exit discharge near Room 222 was covered with an accumulation of debris.

St. Helena Cardiology Outpatient Services:
3. On 7/12/12, at 7:58 a.m., the tamper switches to the fire alarm system's fire pump water valves were activated by closing of the valves. No tamper signals were received at the Fire Alarm Control Panel for 2 of 3 tamper switches. The facility's central monitoring company's activity report was requested, but not received. There was no documentation that the monitoring company had received the signals.

4. On 7/12/12, at 8:15 a.m., the annual report and the quarterly reports were requested for St. Helena Cardiology Outpatient Services. The riser was stamped with a current annual inspection dated 1/2012, but no report was available for review. The Facilities Manager stated that they did not believe that the quarterly inspections of the sprinkler system had been done.

Based on observation and record review, the facility failed to maintain their emergency generator. This was evidenced by failing to perform weekly inspections on the generator. This deficient practice affected all patients, staff, and visitors in St. Helena Hospital, and had the potential for generator failure during the loss of power.

Findings:

During a tour of the facility with the Facilities Manager, the generator was observed, and documents were reviewed.

St. Helena Hospital:
On 7/11/12, at 4:00 p.m., the generator's records were reviewed, and showed that weekly inspection had not been done since 5/10/2011. The Facilities Manager stated that no records were available.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.

19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

Based on record review and interview, the facility failed to maintain evacuation plans. This was evidenced by outdated evacuation plans posted throughout the building. This had the potential to delay evacuation during an emergency, and affected the entire facility at St. Helena Hospital.

Findings:

During a tour of the facility with the Facilities Manager, the disaster manual and evacuation plans were reviewed.

St. Helena Hospital:
On 7/11/12, at 10:36 a.m. the evacuation plans posted throughout the facility included an exit that was no longer available by the Emergency Department. The Facilities Manager stated that the exit that was once available by the Emergency Department was undergoing construction, and the exit was no longer available for evacuation.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.2 Emergency Forces Notification. Fire department notification shall be accomplished in accordance with 9.6.4.

9.6.4 Emergency Forces Notification. Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency. Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm Code:
(1) Auxiliary alarm system
(2) Central station connection
(3) Proprietary system
(4) Remote station connection

NFPA 72, National Fire Alarm Code, 1999 Edition
5-3.4.7 The maximum elapsed time from sensing a fire alarm at an initiating device or initiating device circuit until it is recorded or displayed at the proprietary supervising station shall not exceed 90 seconds.

7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.

7-3.2* Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.

Based on observation, interview and record review, the facility failed to maintain their fire alarm system in accordance with NFPA, and NFPA 72. This was evidenced by no current annual fire alarm report available for review, and by no evidence that fire alarm devices had reported to a central monitoring station. This affected the entire facility at St. Helena Cardiology Outpatient Services, and the entire facility at Rehab Outpatient Services. This had the potential to delay the response of fire emergency personnel, increasing the risk of injury to patients, visitors, and staff.

Findings:

During a tour of the facility with the Facilities Manager, the fire alarm system was tested, observed, and records were reviewed.

St. Helena Cardiology Outpatient Services:
1. On 7/12/12, at 8:15 a.m., the annual fire alarm inspection report was requested for St. Helena Cardiology Outpatient Services. The Facilities Manager stated that no current annual fire alarm system testing had been done at the facility.

2. On 7/12/12, at 8:30 a.m., the activity report from the facility's central monitoring station had been requested for all the fire alarm devices activated from 7:30 a.m., to 8:00 a.m., at St. Helena Cardiology Outpatient Services. The Director of Quality/Infection Prevention stated that current issues with the monitoring company prevented them from obtaining an activity report for the fire alarm devices activated on 7/12/12.

Rehab Outpatient Services:
3. On 7/12/12, at 11:30 a.m., the annual fire alarm inspection report was requested for Rehab Outpatient Services. The Facilities Manager stated that no current annual fire alarm system testing had been done at the facility.

NFPA 101, Life Safety Code, 2000 Edition
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, waterflow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by tamper switches that failed to send signals to the central monitoring company and to the Fire Control Panel, no quarterly inspection of the sprinkler system, inspection reports not available for review, and by sprinkler heads with debris. This deficient practice affected all patients, staff, and visitors in the St. Helena Cardiology Outpatient Services, and this affected 1 of 5 Smoke Compartments in St. Helena Hospital. This could result in the failure of the sprinkler system in the event of a fire.

Findings:

During a tour of the facility with the Facilities Manager, the sprinkler system was tested and observed, and records were reviewed.

St. Helena Hospital:
1. On 7/11/12, at 10:33 a.m., the sprinkler head located outside the building by Room 212 was covered with an accumulation of debris.

2. On 7/11/12, at 10:40 a.m., the sprinkler head located in the storage room by the exit discharge near Room 222 was covered with an accumulation of debris.

St. Helena Cardiology Outpatient Services:
3. On 7/12/12, at 7:58 a.m., the tamper switches to the fire alarm system's fire pump water valves were activated by closing of the valves. No tamper signals were received at the Fire Alarm Control Panel for 2 of 3 tamper switches. The facility's central monitoring company's activity report was requested, but not received. There was no documentation that the monitoring company had received the signals.

4. On 7/12/12, at 8:15 a.m., the annual report and the quarterly reports were requested for St. Helena Cardiology Outpatient Services. The riser was stamped with a current annual inspection dated 1/2012, but no report was available for review. The Facilities Manager stated that they did not believe that the quarterly inspections of the sprinkler system had been done.

Based on observation and record review, the facility failed to maintain their emergency generator. This was evidenced by failing to perform weekly inspections on the generator. This deficient practice affected all patients, staff, and visitors in St. Helena Hospital, and had the potential for generator failure during the loss of power.

Findings:

During a tour of the facility with the Facilities Manager, the generator was observed, and documents were reviewed.

St. Helena Hospital:
On 7/11/12, at 4:00 p.m., the generator's records were reviewed, and showed that weekly inspection had not been done since 5/10/2011. The Facilities Manager stated that no records were available.