HospitalInspections.org

Bringing transparency to federal inspections

173 MIDDLE STREET

LANCASTER, NH 03584

HVAC

Tag No.: K0521

NFPA 101 (2012 edition) Life Safety Code
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment.
Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance NFPA 90 A

NFPA 90 A (2012 edition) Standard for the Installation of Air-Conditioning and Ventilation Systems
5.4.7 Installation
5.4.7.1 Fire dampers, including their sleeves: smoke dampers: and ceiling dampers shall be installed in accordance with the conditions of their listings and the manufacturer's installation instructions and the requirements of NFPA 80, Standard for Fire Doors and other Opening Protective's.

NFPA 80 (2010 edition)
19.4 Periotic Testing
19.4.1 Each damper shall be tested and inspected 1 year after installation.
19.4.1.1 The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every 6 years.
19.4.2 All tests shall be completed in a safe manner by personnel wearing PPE.
19.4.3 Full unobstructed access to the fire or combination fire/smoke damper shall be verifies and corrected as required.
19.4.4 If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock in place if so equipped.
19.4.5 The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.
19.4.6 The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations.
19.4.7 The damper shall not be blocked from closure in any way.
19.4.8 The fusible link shall be reinstalled after testing is complete.
19.4.8.1 If the link is damaged or painted, it shall be replaced with a link of the same size,, temperature, and load rating.
19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper, date of the inspection, name of the inspector, and deficiencies discovered.
19.4.9.1 The documentation shall have a place to indicate when and how the deficiencies were corrected.
19.4.10 All documentation shall be maintain for review by the AHJ.

Based on record review and interview the facility failed to ensure that fire dampers are tested and inspected every 6 years.

Findings include:

Record review during tour on 08/21/18 between 9:30 a.m. and 10:30 a.m. with Staff A (Facilities Director) and Staff B (Assistant Facilities Director) revealed that an audit of the HVAC system fire dampers was conducted on 06/27/17, with 15 fire dampers failing the inspection due to "lack of access panels" and 3 fire dampers listed in non-rated walls. Service or corrective actions could not be verified at the time of survey.

Interview with Staff A and Staff B confirmed the above findings.