HospitalInspections.org

Reference NFPA 101, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.3.6.1 states when pipes, conduits, cables, wires, air ducts and similar building service equipment pass through floors and smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose. Sleeves are shall be solidly set and the space between the item and the sleeve shall be sealed by approved methods.

Section 8.3.5.3 Required smoke dampers in air transfer openings shall close upon the detection of smoke by approved smoke detectors in accordance with NFPA 72, (National Fire Alarm Code).


Based on observation and staff interview, the facility failed to ensure smoke/fire barrier walls were constructed and properly protected from penetrations in accordance with NFPA 101, section 8.3. Incomplete construction, unprotected penetrations, openings and gaps in smoke/fire barrier walls would permit the movement of smoke and/or fire from one compartment to another, which in the event of fire presents a risk of potential harm to all staff and two (2) patients in the facility. Patients were identified by the Patient List Report provided by the Plant Operations Assistant on 08/27/13 at 11:00 am. The findings are:


A. On 08/28/13 at 8:20 am, during observation, there were three (3) 2-inch diameter penetrations located above the fire/smoke separation doors at the 2-hour fire/smoke barrier wall at Corridor H178.

B On 08/28/13 at 8:40 am, during observation, there were three (3) 1-inch diameter penetrations located above the fire/smoke separation doors at the 1-hour fire/smoke barrier wall at Corridor H160.

C. On 08/28/13 at 8:50 am, during interview, the Plant Operations Assistant stated he was unaware of the penetrations.

D. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.

NFPA 101, 2000 Edition 4.6.12.3 requires equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

Reference NFPA 101, 2000
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.


7.9.2 Performance of System.
7.9.2.2*
The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities


Based on observation and staff interview, the facility's practice failed to ensure battery operated emergency lighting is tested monthly for 30 seconds and is operational in the event of an emergency. This deficient practice presents a risk of potential harm by fire or smoke to all staff working within the penthouse mechanical room. The findings are:

A. On 08/27/13 at 4:45 pm, during observation, two (2) battery operated emergency light fixtures located at the penthouse mechanical room failed to work when tested.

B. On 08/27/13 at 4:50 pm, during interview, the Plant Operations Assistant stated the two (2) battery operated emergency light fixtures have not been tested monthly for 30 seconds or annually for 1 1/2 hours.

C. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.

Reference NFPA 101, 2000 Edition
Section. 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift.


Based on record review and staff interview, the facility failed to conduct fire drills at least quarterly for the evening shift (6:00 pm - 6:00 am) to ensure preparedness for emergency response (federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This deficient practice presents a risk that the facility staff is not prepared in the event of a fire emergency, which could result in harm by fire to all staff and two (2) patients in the facility. Patients were identified by the Patient List Report provided by the Plant Operations Assistant on 08/27/13 at 11:00 am. The findings are:

A. On 08/27/13 at 11:45 am, during interview, the Plant Operations Assistant indicated the facility has two (2) nursing shifts:

Day Shift (6:00 am - 6:00 pm)
Evening Shift (6:00 pm - 6:00 am)

B. During a review of facility fire drill records with the Plant Operations Assistant and the Assistant Administrator, fire drill records were not in evidence and available for review between 12/28/12 and 08/27/13 (date of survey) for the evening shift (6:00 pm - 6:00 am).

C. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.

Reference NFPA 72: Section 7-1.1.1
Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Reference NFPA 72: Section 7-1.1.2
System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.

Reference NFPA 72
National Fire Alarm Code?
1999 Edition
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.
A-7-3.2 Explanatory
It is suggested that the annual test be conducted in segments so that all devices are tested annually.

Reference NFPA 72
National Fire Alarm Code?
1999 Edition
7-5.2 Maintenance, Inspection, and Testing Records.
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.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) * Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)


Based on record review and staff interview, the facility failed to ensure the fire alarm system is tested and inspected annually in accordance with figure 7-5.2.2 in NFPA 72 (National Fire Alarm Code). This failed practice presents a risk that the fire alarm system would not be operational in the event of fire or other emergency and would prevent staff from responding in a timely manner for safe evacuation of patients. This deficient practice presents a risk of potential harm by fire to all staff and two (2) patients in the facility. Patients were identified by the Patient List Report provided by the Plant Operations Assistant on 08/27/13 at 11:00 am. The findings are:




A. During a review of the fire alarm system inspection and testing records with the Plant Operations Assistant, a fire alarm system inspection report in accordance with figure 7-5.2.2 NFPA 72 (National Fire Alarm Code) was not available for review indicating the fire alarm system was inspected within the previous year.

B. On 08/27/13 at 12:00 pm, during interview, the Plant Operations Assistant acknowledged the concern.

C. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.








Reference NFPA 72
7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
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. (72:7-3.2.1)





Based on record review and staff interview, the facility failed to ensure the fire alarm system smoke detectors were maintained and tested for sensitivity periodically in accordance with NFPA 72 (National Fire Alarm Code). This presents a potential risk of patients and staff failing to be notified of fire or smoke due to a faulty smoke detector. This deficient practice presents a risk of potential harm by fire or smoke to all staff and two (2) patients in the facility. Patients were identified by the Patient List Report provided by the Plant Operations Assistant on 08/27/13 at 11:00 am. The findings are:




A. During a review of the fire alarm system inspection and testing records with the Assistant Administrator and the Plant Operations Assistant, there was no evidence of sensitivity testing of the facility smoke detectors available for review.

B. On 08/27/13 at 11:55 am, during interview, the Plant Operations Assistant stated sensitivity testing has not been done for the facility smoke detectors.

C. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.

Reference NFPA 110 (Standard for Emergency and Standby Power System, 1999 Edition)
Section 6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

* Light loading creates a condition termed wet stacking, indicating the presence of unburned fuel or carbon, or both, in the exhaust system. Its presence is readily indicated by the presence of continual black smoke during engine-run operation. The testing requirements of 6-4.2 are intended to reduce the possibility of wet stacking.

6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
6-4.3
Load tests of generator sets shall include complete cold starts.

NFPA 110
6-4 Operational Inspection and Testing.
6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.


Based on record review and staff interview, the facility failed to ensure the emergency generator was being exercised monthly for a minimum of 30 minutes in accordance with NFPA 110 (Standard for Emergency and Standby Power Systems). It is essential that monthly underload testing (all engines are designed to operate under varying load, ranging from the maximum down to the minimum) is conducted to ensure the emergency generator is reliable and emergency power is available in the event of primary power failure and fire emergency. An unreliable emergency generator may result in no emergency power or lighting and creates a risk of potential harm by fire and injury to all staff and two (2) patients in the facility. Patients were identified by the Patient List Report provided by the Plant Operations Assistant on 08/27/13 at 11:00 am. The findings are:


A. During a review of the generator testing logbook with the Plant Operations Assistant, there was no evidence the emergency generator was exercised underload monthly for a minimum of 30 minutes.

B. On 08/27/13 at 11:10 am, during interview, the Plant Operations Assistant stated the generator runs automatically every weekly but there is no documentation of monthly underload testing.

C. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.




NFPA 110, Chapter 6, Routine Maintenance and Operational Testing
(Requirements for Weekly, Monthly, Semi-annually, Annually, and every 2 years are explained.)





Based on record review and staff interview, the facility's practice failed to ensure specific gravity was being tested for all generator batteries in accordance with NFPA 99 (Health Care Facilities) and NFPA 110 (Standard for Emergency and Standby Power Systems). Specific gravity shall be tested and recorded at least once a month for all generator batteries to determine their serviceability. Failing to conduct specific gravity testing may result in weak generator batteries and may potentially prevent the generator from providing emergency power and emergency illumination in the event of a fire emergency. This condition presents a risk of potential harm by fire to all staff and two (2) patients in the facility. Patients were identified by the Patient List Report provided by the Plant Operations Assistant on 08/27/13 at 11:00 am. The findings are:


A. During a review of the generator testing logbook with the Plant Operations Assistant, there was no evidence the batteries for the emergency generator were being documented for specific gravity.

B. On 08/27/13 at 11:20 am, during interview, the Plant Operations Assistant acknowledged specific gravity testing for the emergency generator batteries were not being documented.

C. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.

Reference NFPA 101, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.3.6.1 states when pipes, conduits, cables, wires, air ducts and similar building service equipment pass through floors and smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose. Sleeves are shall be solidly set and the space between the item and the sleeve shall be sealed by approved methods.

Section 8.3.5.3 Required smoke dampers in air transfer openings shall close upon the detection of smoke by approved smoke detectors in accordance with NFPA 72, (National Fire Alarm Code).


Based on observation and staff interview, the facility failed to ensure smoke/fire barrier walls were constructed and properly protected from penetrations in accordance with NFPA 101, section 8.3. Incomplete construction, unprotected penetrations, openings and gaps in smoke/fire barrier walls would permit the movement of smoke and/or fire from one compartment to another, which in the event of fire presents a risk of potential harm to all staff and two (2) patients in the facility. Patients were identified by the Patient List Report provided by the Plant Operations Assistant on 08/27/13 at 11:00 am. The findings are:


A. On 08/28/13 at 8:20 am, during observation, there were three (3) 2-inch diameter penetrations located above the fire/smoke separation doors at the 2-hour fire/smoke barrier wall at Corridor H178.

B On 08/28/13 at 8:40 am, during observation, there were three (3) 1-inch diameter penetrations located above the fire/smoke separation doors at the 1-hour fire/smoke barrier wall at Corridor H160.

C. On 08/28/13 at 8:50 am, during interview, the Plant Operations Assistant stated he was unaware of the penetrations.

D. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.

NFPA 101, 2000 Edition 4.6.12.3 requires equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

Reference NFPA 101, 2000
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.


7.9.2 Performance of System.
7.9.2.2*
The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities


Based on observation and staff interview, the facility's practice failed to ensure battery operated emergency lighting is tested monthly for 30 seconds and is operational in the event of an emergency. This deficient practice presents a risk of potential harm by fire or smoke to all staff working within the penthouse mechanical room. The findings are:

A. On 08/27/13 at 4:45 pm, during observation, two (2) battery operated emergency light fixtures located at the penthouse mechanical room failed to work when tested.

B. On 08/27/13 at 4:50 pm, during interview, the Plant Operations Assistant stated the two (2) battery operated emergency light fixtures have not been tested monthly for 30 seconds or annually for 1 1/2 hours.

C. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.

Reference NFPA 101, 2000 Edition
Section. 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift.


Based on record review and staff interview, the facility failed to conduct fire drills at least quarterly for the evening shift (6:00 pm - 6:00 am) to ensure preparedness for emergency response (federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This deficient practice presents a risk that the facility staff is not prepared in the event of a fire emergency, which could result in harm by fire to all staff and two (2) patients in the facility. Patients were identified by the Patient List Report provided by the Plant Operations Assistant on 08/27/13 at 11:00 am. The findings are:

A. On 08/27/13 at 11:45 am, during interview, the Plant Operations Assistant indicated the facility has two (2) nursing shifts:

Day Shift (6:00 am - 6:00 pm)
Evening Shift (6:00 pm - 6:00 am)

B. During a review of facility fire drill records with the Plant Operations Assistant and the Assistant Administrator, fire drill records were not in evidence and available for review between 12/28/12 and 08/27/13 (date of survey) for the evening shift (6:00 pm - 6:00 am).

C. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.

Reference NFPA 72: Section 7-1.1.1
Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Reference NFPA 72: Section 7-1.1.2
System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.

Reference NFPA 72
National Fire Alarm Code?
1999 Edition
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.
A-7-3.2 Explanatory
It is suggested that the annual test be conducted in segments so that all devices are tested annually.

Reference NFPA 72
National Fire Alarm Code?
1999 Edition
7-5.2 Maintenance, Inspection, and Testing Records.
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.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) * Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)


Based on record review and staff interview, the facility failed to ensure the fire alarm system is tested and inspected annually in accordance with figure 7-5.2.2 in NFPA 72 (National Fire Alarm Code). This failed practice presents a risk that the fire alarm system would not be operational in the event of fire or other emergency and would prevent staff from responding in a timely manner for safe evacuation of patients. This deficient practice presents a risk of potential harm by fire to all staff and two (2) patients in the facility. Patients were identified by the Patient List Report provided by the Plant Operations Assistant on 08/27/13 at 11:00 am. The findings are:




A. During a review of the fire alarm system inspection and testing records with the Plant Operations Assistant, a fire alarm system inspection report in accordance with figure 7-5.2.2 NFPA 72 (National Fire Alarm Code) was not available for review indicating the fire alarm system was inspected within the previous year.

B. On 08/27/13 at 12:00 pm, during interview, the Plant Operations Assistant acknowledged the concern.

C. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.








Reference NFPA 72
7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
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. (72:7-3.2.1)





Based on record review and staff interview, the facility failed to ensure the fire alarm system smoke detectors were maintained and tested for sensitivity periodically in accordance with NFPA 72 (National Fire Alarm Code). This presents a potential risk of patients and staff failing to be notified of fire or smoke due to a faulty smoke detector. This deficient practice presents a risk of potential harm by fire or smoke to all staff and two (2) patients in the facility. Patients were identified by the Patient List Report provided by the Plant Operations Assistant on 08/27/13 at 11:00 am. The findings are:




A. During a review of the fire alarm system inspection and testing records with the Assistant Administrator and the Plant Operations Assistant, there was no evidence of sensitivity testing of the facility smoke detectors available for review.

B. On 08/27/13 at 11:55 am, during interview, the Plant Operations Assistant stated sensitivity testing has not been done for the facility smoke detectors.

C. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.

Reference NFPA 110 (Standard for Emergency and Standby Power System, 1999 Edition)
Section 6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

* Light loading creates a condition termed wet stacking, indicating the presence of unburned fuel or carbon, or both, in the exhaust system. Its presence is readily indicated by the presence of continual black smoke during engine-run operation. The testing requirements of 6-4.2 are intended to reduce the possibility of wet stacking.

6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
6-4.3
Load tests of generator sets shall include complete cold starts.

NFPA 110
6-4 Operational Inspection and Testing.
6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.


Based on record review and staff interview, the facility failed to ensure the emergency generator was being exercised monthly for a minimum of 30 minutes in accordance with NFPA 110 (Standard for Emergency and Standby Power Systems). It is essential that monthly underload testing (all engines are designed to operate under varying load, ranging from the maximum down to the minimum) is conducted to ensure the emergency generator is reliable and emergency power is available in the event of primary power failure and fire emergency. An unreliable emergency generator may result in no emergency power or lighting and creates a risk of potential harm by fire and injury to all staff and two (2) patients in the facility. Patients were identified by the Patient List Report provided by the Plant Operations Assistant on 08/27/13 at 11:00 am. The findings are:


A. During a review of the generator testing logbook with the Plant Operations Assistant, there was no evidence the emergency generator was exercised underload monthly for a minimum of 30 minutes.

B. On 08/27/13 at 11:10 am, during interview, the Plant Operations Assistant stated the generator runs automatically every weekly but there is no documentation of monthly underload testing.

C. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.




NFPA 110, Chapter 6, Routine Maintenance and Operational Testing
(Requirements for Weekly, Monthly, Semi-annually, Annually, and every 2 years are explained.)





Based on record review and staff interview, the facility's practice failed to ensure specific gravity was being tested for all generator batteries in accordance with NFPA 99 (Health Care Facilities) and NFPA 110 (Standard for Emergency and Standby Power Systems). Specific gravity shall be tested and recorded at least once a month for all generator batteries to determine their serviceability. Failing to conduct specific gravity testing may result in weak generator batteries and may potentially prevent the generator from providing emergency power and emergency illumination in the event of a fire emergency. This condition presents a risk of potential harm by fire to all staff and two (2) patients in the facility. Patients were identified by the Patient List Report provided by the Plant Operations Assistant on 08/27/13 at 11:00 am. The findings are:


A. During a review of the generator testing logbook with the Plant Operations Assistant, there was no evidence the batteries for the emergency generator were being documented for specific gravity.

B. On 08/27/13 at 11:20 am, during interview, the Plant Operations Assistant acknowledged specific gravity testing for the emergency generator batteries were not being documented.

C. On 08/28/13 at 11:15 am, the Administrator, Assistant Administrator, and the Plant Operations Assistant acknowledged the findings at the exit conference.