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Tag No.: K0056
NFPA 13, Standard for the Installation of Sprinkler Systems
1-6 Level of Protection.
1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.
This Standard is not met as evidenced by:
Based on observation it was determined the hospital failed to provide automatic sprinkler coverage to all portions of the facility.
Findings include:
1. On 11/28/11 at approximately 2:25 p.m., an inspection of an equipment storage room located in the OR was conducted. At this time an electrical panel closet approximately twelve (12) feet by two (2) feet was observed not to have sprinkler coverage.
2. On 11/28/11 at approximately 2:57 p.m., an inspection of the outpatient surgery holding area was conducted. At this time four (4) closets approximately two (2) feet by two (2) feet were observed not to have sprinkler coverage.
3. On 11/28/11 at approximately 3:00 p.m., an inspection of the central supply reprocessing unit located in the basement was conducted. At this time there was no sprinkler coverage in this area.
Tag No.: K0069
NFPA (National Fire Protection Association) 17A - Standard for Wet Chemical Extinguishing Systems
Chapter 5 - Inspection, Maintenance, and Recharging
5-2 Owner's Inspection.
5-2.1
On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.
5-2.2
If any deficiencies are found, appropriate corrective action shall be taken immediately.
5-2.3
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.
5-2.4
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained until the next semiannual maintenance.
This Standard is not met as evidenced by:
Based on observation and staff interview it was determined the hospital failed to inspect the rangehood extinguishing system in accordance with NFPA 17A.
Findings include:
1. On 11/30/11 at approximately 10:25 a.m., the Hospital rangehood extinguishing system located in the kitchen was inspected. During this inspection, the service tag attached to the rangehood extinguishing system was observed not to have a date or initials recorded, to verify a monthly inspection was conducted on the system. Therefore, a monthly inspection record was not available for the past twelve (12) months.
2. An interview with the hospital engineering manager on 11/30/11 at approximately 10:45 a.m., revealed a monthly inspection was not conducted on the rangehood extinguishing system.
Tag No.: K0056
NFPA 13, Standard for the Installation of Sprinkler Systems
1-6 Level of Protection.
1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.
This Standard is not met as evidenced by:
Based on observation it was determined the hospital failed to provide automatic sprinkler coverage to all portions of the facility.
Findings include:
1. On 11/28/11 at approximately 2:25 p.m., an inspection of an equipment storage room located in the OR was conducted. At this time an electrical panel closet approximately twelve (12) feet by two (2) feet was observed not to have sprinkler coverage.
2. On 11/28/11 at approximately 2:57 p.m., an inspection of the outpatient surgery holding area was conducted. At this time four (4) closets approximately two (2) feet by two (2) feet were observed not to have sprinkler coverage.
3. On 11/28/11 at approximately 3:00 p.m., an inspection of the central supply reprocessing unit located in the basement was conducted. At this time there was no sprinkler coverage in this area.
Tag No.: K0069
NFPA (National Fire Protection Association) 17A - Standard for Wet Chemical Extinguishing Systems
Chapter 5 - Inspection, Maintenance, and Recharging
5-2 Owner's Inspection.
5-2.1
On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.
5-2.2
If any deficiencies are found, appropriate corrective action shall be taken immediately.
5-2.3
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.
5-2.4
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained until the next semiannual maintenance.
This Standard is not met as evidenced by:
Based on observation and staff interview it was determined the hospital failed to inspect the rangehood extinguishing system in accordance with NFPA 17A.
Findings include:
1. On 11/30/11 at approximately 10:25 a.m., the Hospital rangehood extinguishing system located in the kitchen was inspected. During this inspection, the service tag attached to the rangehood extinguishing system was observed not to have a date or initials recorded, to verify a monthly inspection was conducted on the system. Therefore, a monthly inspection record was not available for the past twelve (12) months.
2. An interview with the hospital engineering manager on 11/30/11 at approximately 10:45 a.m., revealed a monthly inspection was not conducted on the rangehood extinguishing system.