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Based on observation and facility staff interview, the facility failed to ensure that one of one fire alarm systems was installed per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The deficient practice has the potential to effect all facility patients, staff and visitors. The deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was eight.

1. Observation on 2/5/18, during the facility tour, showed all exit corridors did not have complete smoke detector coverage.

During an interview on 2/5/18 at 2:37 P.M., The Lead Maintenance Technician said that the facility did not have complete smoke
detector coverage.

Refer to National Fire Protection Association 72, 2010 edition, section 17.5.3.2

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on interview and record review facility staff failed to maintain an out of service policy for the fire alarm system. The facility census was eight.

1. Record review on 2/6/18 of the facility records did not show an out of service policy for the fire alarm system.

During an interview on 2/6/18 at 8:15 A.M., the Director of Facilities Environmental Services confirmed that the facility did not have an out of service policy for the fire alarm system.


NFPA Standard: 2012 NFPA 101, 9.6.1.6 Where a required fire alarm is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection per NFPA 72, National Fire Alarm and Signaling Code. This deficient practice has the potential to effect all facility patients, staff and visitors. This deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was 8.

Observations on 2/5/18, during the facility tour, showed the following areas open to the corridor:

- admitting area;
- out patient services;
- pharmacy;
- lab.

Observation showed the areas did not have smoke detection.

During an interview on 2/5/18 at 3:05 P.M., the Lead Maintenance Technician confirmed the areas are open to the corridor and did not have smoke detection.

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on interview and record review facility staff failed to maintain an out of service policy for the sprinkler system. The facility census was eight.

1. Record review on 2/6/18 of the facility records did not show an out of service policy for the sprinkler system.

During an interview on 2/6/18 at 8:15 A.M., the Director of Facilities Environmental Services confirmed that the facility did not have an out of service policy for the sprinkler system.

Review of the National Fire Protection Association (NFPA) 25 (Inspection, Testing and Maintenance of Water-Based Fire Protection Systems), 2011 Edition, showed:

-4.1.9.1 Where an impairment to a water-based fire protection system occurs, the procedures outlined in Chapter 15 of this standard shall be followed, including the attachment of a tag to the impaired system;
-15.2.1 The property owner or designated representative shall assign an impairment coordinator to comply with the requirements of this chapter;
-15.2.3 Where the lease, written use agreement, or management contract specifically grants the authority for inspection, testing, and maintenance of the fire protection system(s) to the tenant, management firm, or managing individual, the tenant, management firm, or managing individual shall assign a person as impairment coordinator;
-15.3.1* A tag shall be used to indicate that a system, or part thereof, has been removed from service;
-15.3.2* The tag shall be posted at each fire department connection and the system control valve, and other locations required by the authority having jurisdiction, indicating which system, or part thereof, has been removed from service;
-15.5.1 All preplanned impairments shall be authorized by the impairment coordinator;
-15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service.
(b)*An approved fire watch.
(c)*Establishment of a temporary water supply.
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire.
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site;
-*A.15.3.1 A clearly visible tag alerts building occupants and the fire department that all or part of the water-based fire protection system is out of service. The tag should be weather resistant, plainly visible, and of sufficient size [typically 4 in. × 6 in. (100 mm × 150 mm)]. The tag should identify which system is impaired, the date and time impairment began, and the person responsible;
-*A.15.5.2(4)(b) A fire watch should consist of trained personnel
who continuously patrol the affected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure that the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly;
-*A.15.5.2(4)(c) Temporary water supplies are possible from a number of sources, including use of a large-diameter hose from a fire hydrant to a fire department connection, use of a portable tank and a portable pump, or use of a standby fire department pumper and/or tanker.
-15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping and equipment failure;
-15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage;
-15.6.3 The coordinator shall implement the steps outlined in Section 15.5;
-15.7 Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:
(1) Any necessary inspections and tests have been conducted to verify that the affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.

Based on record review and interview, the facility failed to ensure that all building systems had been assigned a risk assessment category. The facility census was eight.

1. Review of the facility documents for fire safety, building system tests, and policies showed no assessment of which systems were critical for patient safety.

During an interview on 2/6/18 at 8:05 A.M. the Director of Facilities Environmental Services said the facility did not have a risk categorical assessment.

NFPA 99 2012 - chapter four Fundamentals, 4.1-4.3

Based on observation and facility staff interview the facility 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 facility census was 8.

1. Observation on 2/5/18, during the facility tour, did not show a remote annunciator panel for the emergency generator in a constantly attended location. Additionally, observation showed a remote annunciator panel in the materials management room.

During an interview on 2/5/18 at 2:32 P.M., the Lead Maintenance Technician said the annunciator panel is in a room attended only during the day..

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.