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NFPA 72 National Fire and Signaling Code (2010 Edition)
14.5.3.1 Sensitivity shall be checked within 1 year after installation.

14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3

14.4.5.3.3 After the second required calibration test, if sensitivity
tests indicate that the device 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.


Based on observation and interview, facility failed to ensure smoke detection devices were tested every two (2) years as required. Not testing detection devices for proper sensitivity levels, could result in the delay of detecting a fire. This failed practice presents a risk of potential harm by fire to all ten (10) patients as identified by the census list provided by the Facilities Services Director on 01/10/17. The findings are:

A. On 01/10/17, during fire alarm record review, no documentation was provided to indicate sensitivity testing had been conducted within the last two (2) years.

B. On 01/11/17, during interview, Facilities Services Director called the fire alarm servicing contractor to verify if sensitivity tests had been conducted. The contractor advised tests had not been done, and would schedule. Facilities Services Director acknowledged the finding.

NFPA 80 (2010 EDITION)
Chapter 7 Swinging Doors with Fire Door Hardware
7.1 Doors.
7.1.1 General. This chapter shall cover the installation of
swinging doors with fire door hardware.
7.1.2 Components. Afire door assembly shall consist of components
that are separate products incorporated into the assembly.
7.1.3 Mounting of Doors.
7.1.3.1 Swinging tin-clad doors and flush- or corrugated-type
sheet metal doors with fire door hardware shall be flush or lap
mounted.
7.1.3.2 Flush-mounted doors shall be hung in steel channel
frames securely anchored to the wall construction.
7.1.3.3 Lap-mounted doors shall be hung on the surface of
the wall and shall lap the opening at least 4 in. (102 mm) at the
top and on each side.
7.1.4 Operation of Doors.
7.1.4.1 The doors shall swing easily and freely on their hinges.
7.1.4.2 The latches shall operate freely.


Based on observation and interview, facility failed to ensure all fire door assemblies in the facility were able to freely close and latch. Not having fire door assemblies latch could result in the passage of fire/smoke from one area to other areas of the facility. This failed practice presents a risk of potential harm by fire/smoke to all ten (10) patients as identified by the census list provided by the Facilities Services Director on 01/10/17. The findings are:

A. On 01/11/17 at 7:40 am, observation of the fire doors located at the Emergency Room Entrance, when tested, did not fully close to the latched position.

B. On 01/11/17 at 2:30 pm, during interview, the Facilities Services Director stated the doors will be adjusted right away to ensure they properly latch, acknowledging the finding.

NFPA 101 (2012 EDITION)
19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.


Based on record review and interview, the facility failed to ensure evacuation drills were conducted quarterly on each shift to familiarize staff with evacuation procedures. Not conducting drills, as required, could result in patients not being evacuated in a timely manner by staff during a fire/emergency. This failed practice presents a risk of potential harm by fire to all ten (10) patients as identified by the census list provided by the Facilities Services Director on 01/11/16. The findings are:


A. Facility has two shifts: 1st Shift - 7:00 AM through 7:00 PM
2nd Shift - 7:00 PM through 7:00 AM

B. On 01/11/16, at 10:15 am, during record review of evacuation drills, the facility failed to conduct fire evacuation drills for both shifts, for the last quarter of the year (2016). The last drill conducted (for both shifts), was the 29th of December, 2016. This exceeds the required 90-day spacing between drills.

C. On 01/11/16, at 2:30 pm, during interview, the Facilities Services Director stated the staff individual who conducts drills had been out on medical leave and he simply forgot to conduct last quarter drills, for the year of 2016.

Reference NFPA 110 (Standard for Emergency and Standby Power System, 2010 Edition)

8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate KW rating

8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

A.8.4.2 (Appendix included for guidance only) 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 continuous black smoke during engine-run operation. The testing requirements of 8-4.2 are intended to reduce the possibility of wet stacking.



Based on record review and interview, the facility failed to ensure a load bank test (generator supplied with supplemental electrical load) was conducted at least annually, when the emergency generator is unable to achieve a minimum of thirty (30) percent of its name plate rating when running monthly underload (electrical demand placed on prime mover) as required by NFPA 110 (Standard for Emergency and Standby Power Systems). This failed practice is likely to result in the facility's emergency generator "wet stacking" a condition that results from light loading. Over time, excessive wet stacking could result in loss of engine performance or premature engine failure, which would leave the facility without a source of emergency power. In the event of primary power failure, this deficient practice presents a risk of potential harm to all 10 patients, as identified by the census list provided by the Facilities Services Director on 01/11/17. The findings are:

A. On 01/10/17 record review of the underload testing logbook with the Facilities Services Director revealed no evidence the underload testing for the emergency generator was greater than or equal to thirty (30) percent of its name plate rating (capacity).

B. On 01/11/17 at 9:45 am, during interview, the Facilities Services Director stated that since the generator couldn't run a load at 30% of the plated load, they have a company perform an annual load bank test.

C. Record review of the Annual Load Bank test documentation, revealed a date of December 2015, which is past due.

D. On 01/11/17 at 2:30 pm, during interview, the Facilities Services Director stated the emergency generator has already been scheduled for service, acknowledging the finding.