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NFPA 25, 2011 Edition:

13.6.2 Testing.
13.6.2.1* All backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.

13.6.3 Maintenance.
13.6.3.1 Maintenance of all backflow prevention assemblies
shall be conducted by a trained individual following the manufacturer's
instructions in accordance with the procedure and policies of the authority having jurisdiction.


Based on record review, observation and interview, the facility failed to ensure the backflow preventer assembly installed in the facility's wet fire protection system piping, was tested annually as required by NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems). The backflow preventer protects water supplies from contamination or pollution due to backflow from the sprinkler system. This failed practice is likely to result in contamination of the facility's potable water supply, which presents a risk of potential harm to all patients, staff and visitors of the facility. The findings are:


A. Review of the fire sprinkler system maintenance records with the Maintenance Director failed to reveal evidence the backflow preventer assembly for the fire protection system was being inspected annually.

B. On 08/30/17 at 11:45 am, observation of the backflow assembly (located in the hotbox outside) revealed no inspection tag.

C. On 08/30/17 at 11:47 am, during interview, the Maintenance Director stated he had no documentation demonstrating the backflow assembly was being inspected annually.

Reference NFPA 10, 2010 Edition

7.1.1 Responsibility. The owner or designated agent or occupant of a property in which fire extinguishers are located shall be responsible for inspection, maintenance, and recharging. (See 7.1.2.)

7.3.1.1.2 Fire extinguishers shall be internally examined at intervals not exceeding those specified in Table 7.3.1.1.2.

Definition: 3.4.6 Stored-Pressure Fire Extinguisher. A fire extinguisher in which both the extinguishing material and expellant gas are kept in a single container, and that includes a pressure indicator or gauge.


Based on observation and interview, the facility failed to ensure all dry chemical, stored pressure portable fire-extinguishers (see definition above) were subject to a 6 year internal examination as required by NFPA 10 (Standard for Portable Fire Extinguishers). Not maintaining fire extinguishers is likely to result in less than optimal performance in the event of fire, which presents the risk of potential harm to all patients, staff and visitors of the facility. The findings are:

A. On 08/30/17 between 9:00 am and 3:00 pm, observation of the dry chemical, stored pressure fire extinguisher labels throughout the facility indicated a date of 2010, which is past due for their 6 year maintenance.

B. On 08/30/17 at 9:15 am, during interview, the Maintenance Director stated that the professional company that inspects the fire extinguishers also pointed out that the fire extinguishers are due for a 6 year maintenance. He stated there are approximately thirty (30) dry powder fire extinguishers in the building that require the 6 year maintenance.

Reference NFPA 101, 2012 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 8.5.6 Penetrations.

8.5.6.1 The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.


Based on observation and interview, the facility failed to ensure smoke/fire barrier walls were sealed to resist the passage of smoke. Incomplete construction, unprotected penetrations, openings and gaps in smoke/fire barriers walls would permit the movement of smoke from one smoke compartment to another, which in the event of fire, presents the risk of potential harm to all patients, staff and visitors of the facility. The findings are:

A. On 08/30/17 at 2:00 pm, during observation, several four (4) inch by four (4) inch unsealed penetrations and a six (6) inch by ten (10) unsealed cable tray penetration was revealed in the smoke/fire barrier wall located within the laboratory. These penetrations are located above the lay-in ceiling tiles.

B. On 08/30/17 at 2:15 pm, during interview, the Maintenance Director stated he was unaware there were unsealed penetrations in the fire/smoke wall.

Reference NFPA 90A, 2012 Edition

5.4.8 Maintenance.

5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protective's.

5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protective's.


Reference NFPA 80, 2010 Edition

19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.


Reference NFPA 105, 2010 Edition

6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.


Based on record review and interview, the facility failed to ensure fire/smoke dampers were tested and inspected at least every six (6) years as required by NFPA 90A (Standard for Installation of Air Conditioning and Ventilating Systems) and in accordance with NFPA 80 (Standard for Fire Doors and other Opening Protective's) and NFPA 105 (Standard for Smoke Door Assemblies and other Opening Protectives). Without this preventative maintenance and in the event of fire, the distribution of smoke, hot gases and fire could travel from one area to another through the ventilation air duct system, which presents the risk of potential harm to all patients, staff and visitors of the facility. The findings are:


A. Record review of the facility's maintenance records revealed no evidence demonstrating the facility's fire/smoke dampers were being inspected every six years as required for hospitals.

B. Review of the facilities Heating Ventilation Air Conditioning (HVAC) plan set revealed the facility had approximately 40 fire/smoke dampers installed throughout the facility.

C. On 08/30/17 at 9:40 am, during interview, the Maintenance Director stated the last time the dampers were inspected was probably when the facility was built in 2010.

Based on record review and interview, the facility failed to ensure fire drills were conducted at least quarterly on all three nursing shifts 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 could likely result in staff not being adequately prepared to exercise their duties in accordance to the facility's fire preparedness plan in the event of fire, which presents the risk of potential harm to all patients, staff and visitors of the facility. The findings are:

A. Record review of the fire drill log indicated the facility had two (2) nursing shifts:

First Shift (6:00 am - 6:00 pm)
Second Shift (6:00 pm - 6:00 am)

B. Record review of the fire drill log revealed the following:

1. A fire drill was conducted on the second shift on 03/21/17 at 10:00 pm. A fire drill has not been conducted since this time on this shift, which exceeds the 90-day requirement.

C. On 08/30/17 at 10:30 am, during interview, the Maintenance Director stated he conducted too many fire drills on the day shift and not enough fire drills on the night shift.

Reference NFPA 110, Standard for Emergency and Standby Power System

8.4 Operational Inspection and Testing.

8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

8.4.3 The EPS test shall be initiated by simulating a power outage using the test switch(es) on the ATSs or by opening a normal breaker. Opening a normal breaker shall not be required.

8.4.4 Load tests of generator sets shall include complete cold starts.

8.4.6 Transfer switches shall be operated monthly.

8.4.6.1 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.

Definition: A transfer switch is an electrical switch that reconnects electric power source from its primary source to a standby source.


Based on record review and interview, the facility failed to ensure their diesel powered emergency generator, used to protect patients during the times of primary power failure, was being exercised underload monthly for at least 30 minutes and transfer switches (see definition above) were operated monthly as required by NFPA 110 (Standard for Emergency and Standby Power System). It is essential this emergency generator is exercised at least monthly and transfer switches are operated monthly to ensure emergency power and emergency illumination is available in the event of primary power failure. In the event of primary power failure, it is likely this failed practice could leave the facility without a source of emergency power and emergency illumination, which presents a risk of potential harm to all patients, staff and visitors of the facility. The findings are:


A. Record review of the generator's maintenance records revealed no evidence the generator was being tested underload at least once a month. And there was no record the automatic transfer switches were operated at least monthly.

B. On 08/30/17 at 10:20 am, during interview, the Maintenance Director stated the generator automatically starts and runs once a week but he stated he didn't think the generator was running underload. He stated he has a professional company perform an annual load bank every year. When asked if he was transferring power via the transfer switches, he stated that there were three (3) transfer switches and he was not testing them.



NFPA 110 Standard for Emergency and Standby Power Systems (2010 EDITION)

8.3.7* Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturers specifications.

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted.

8.3.7.2 Defective batteries shall be replaced immediately upon discovery of defects.


Based on record review and interview, the facility's practice failed to ensure specific gravity was being tested at least monthly for generator starting batteries in accordance with 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. Not testing and monitoring specific gravity levels is likely to result in an unnoticeable drop in battery cranking amps, which may not be adequate to start the emergency generator in the event of power failure. In the event of power failure, this failed practice presents a risk of potential harm to all patients, staff and visitors of the facility. The findings are:


A. Record review of the generator's maintenance log book revealed no evidence specific gravity was being tested.

B. On 08/30/17 at 10:00 am, during interview, the Maintenance Director stated he started he did not know the specific gravity of the batteries was required to be tested every month.



Reference NFPA 110, 2010 Edition

5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.

(Appendix included for guidance only, not regulatory)
A.5.6.5.6 For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.


Based on observation and interview, the facility failed to ensure a remote manual stop station (emergency stop) was provided outside the room housing the prime mover (engine) as required by NFPA 110 (Standard for Emergency and Standby Power Systems). Not having a remote emergency stop located outside the room housing the prime mover can result in harm to persons, fire, mechanical damage, and inadvertent or unintentional operation of the emergency generator. In the event the emergency generator can't be shut down quickly due to the above circumstances, is likely to result in harm to service personnel as well as mechanical failure. Mechanical failure is likely to result in an unreliable source of secondary power in the event of primary power failure, which presents the risk of potential harm to all patients, staff and visitors of the facility. The findings are:

A. On 08/30/17 at 12:15 pm, observation of the emergency generator, which is housed outside in a weatherproof enclosure, revealed the manual remote stop button was located on the generators indicator panel internal to the weatherproof enclosure instead of external to the weatherproof enclosure as required.

B. On 08/30/17 at 12:20 pm, during interview, the Maintenance Director stated the generator was installed when the building was built in 2010. He stated he did not know why a remote emergency stop button was never installed.



Reference NFPA 110, 2010 Edition

8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards (American Society for Testing Materials).


Based on record review and interview, the facility failed to ensure an annual fuel quality test was conducted for the diesel fuel source that serves the emergency generator. Not conducting a fuel quality test at least every 12 months is likely to allow for water, sediment and microbial growth in the fuel tank, which breaks down or degrades fuel and plugs fuel filters, fuel lines and fuel injectors. In the event of primary power failure, the emergency power source (generator) may not come on line, which is likely to leave the facility without a source of emergency power and emergency lighting, which presents the risk of potential harm to all patients, staff and visitors of the facility. The findings are:


A. Record review of facility's emergency generator maintenance log, revealed no evidence that a fuel quality test has been conducted for the diesel fuel source that serves the emergency generator.

B. On 08/30/17 at 11:20 am, during interview, the Maintenance Director stated he was unaware a fuel quality test was required.

Reference NFPA 99, 2012 Edition

4.1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.

4.1.1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code.

4.1.2* Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined
in this code.

4.1.3 Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category
3 requirements as defined in this code.

4.1.4 Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code.

4.2* Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure.

(Appendix included for Guidance only)
A.4.2 Risk assessment should follow procedures such as those outlined in ISO/IEC 31010, Risk Management-Risk Assessment Techniques, NFPA 551, Guide for the Evaluation of Fire Risk Assessments, Guide for the Evaluation of Fire Risk Assessments, SEMI S10-0307E, Safety Guideline for Risk Assessment and Risk Evaluation Process, or other formal process. The results of the assessment procedure should be documented and records retained.

5.1.14.2.2 Maintenance Programs.
5.1.14.2.2.1 Inventories. Inventories of medical gas, vacuum, WAGD, and medical support gas systems shall include at least all source subsystems, control valves, alarms, manufactured assemblies
containing patient gases, and outlets.

5.1.14.2.2.2* Inspection Schedules. Scheduled inspections for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.

5.1.14.2.2.3 Inspection Procedures. The facility shall be permitted to use any inspection procedure(s) or testing methods established through its own risk assessment.

5.1.14.2.2.4 Maintenance Schedules. Scheduled maintenance for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.

5.1.14.2.2.5 Qualifications. Persons maintaining these systems shall be qualified to perform these operations. Appropriate qualification shall be demonstrated by any of the following:
(1) Training and certification through the health care facility by which such persons are employed to work with specific equipment as installed in that facility
(2) Credentialing to the requirements of ASSE 6040, Professional Qualification Standard for Medical Gas Maintenance Personnel (3) Credentialing to the requirements of ASSE 6030, Professional
Qualification Standard for Medical Gas Systems Verifiers


5.1.14.4.4 Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.

5.1.14.4.5 A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be implemented.


Based on record review and interview, the facility failed to ensure a risk assessment was conducted in order to determine the type of medical air/vacuum system installed in the facility (i.e.; Category 1, Category 2, Category 3 or Category 4) and that central supply systems for nonflammable medical gases were inspected at least every 12 months as required by NFPA 99 (Health Facilities Code). Determining the Category through a risk assessment is important in understanding the level of risk to patients and caregivers associated with the failure of a system. Not inspecting nonflammable medical gas systems annually can result in less than optimal system performance during times of demand. This failed practice presents the risk of potential harm to those patients that require the use of medical gases and vacuum. The findings are:

A. On 08/30/17 at 10:45 am, review of the facility's maintenance records revealed no evidence a risk assessment was conducted to demonstrate the category of medical gas/vacuum system in the facility. Also, there was no record the nonflammable medical gas/vacuum system was being inspected at least every 12 months.

B. On 08/30/17, at 10:50 am, during interview, the Maintenance Director stated he did not know if a risk assessment was ever done for the facility. He stated the patients that come to the hospital are stabilized, which may required the use of life support such as a ventilator, and then transported to another hospital with more services. He stated he did not know the medical gas/vacuum system required to be inspected annually.