HospitalInspections.org

The facility did not ensure that a fire alarm system is installed and programmed in accordance with NFPA 72, " National Fire Alarm Code " .
On 11/10/16 at 9:30 AM, The surveyor was not provided with documentation by the Director of Facilities that when the facility added 12 analog smoke detectors the devices that were added were tested and the software and circuits and panel affected by the programming of the new devices were reacceptance tested according to NFPA 72 National Fire Alarm Code 14.4.1.2

The facility did not ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems.
On 11/10/16 at 9:30 AM, The surveyor was provided with documentation by the Director of Facilities that the facility conducted the required dry pipe sprinkler system full trip test in June of 2014. Documentation review indicated that no times were recorded from the trip of the dry pipe valve to when water reached the test outlet as required by NFPA 25