HospitalInspections.org

National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition.

11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months.
11.2.2* All actuation and control components, including remote manual pull stations, mechanical and electrical devices, detectors, and actuators, shall be tested for proper operation during the inspection in accordance with the manufacturer's procedures.
11.2.3 The specific inspection and maintenance requirements of the extinguishing system standards as well as the applicable installation and maintenance manuals for the listed system and service bulletins shall be followed.
11.2.4* Fusible links of the metal alloy type and automatic sprinklers of the metal alloy type shall be replaced at least semiannually except as permitted by 11.2.6 and 11.2.7.
11.2.5. The year of manufacture and the date of installation of the fusible links shall be marked on the system inspection tag.
11.2.5.1 The tag shall be signed or initialed by the installer.


Based on document review and interview, the facility failed to maintain the cooking facility extinguishment systems as required.

Findings include:

On 12/04/19, document review revealed the kitchen cooking facility extinguishment system was last serviced/inspected on 12/28/18. The cooking hood suppressant system inspection, testing and replacement of fusible links is required at least semiannually.

On 12/05/19, a review of the inspection tag attached to the kitchen cooking facility extinguishment system pull device confirmed the system was last serviced/inspected on 12/28/18.

The Maintenance Manager acknowledged that the facility failed to ensure the semi-annual inspection of the kitchen hood extinguishment system was completed.

National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 Edition
10.18 Documentation.
10.18.1 Approval and Acceptance.
10.18.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring.
10.18.1.2* At the authority having jurisdiction's request, complete information regarding the system or system alterations, including specifications, type of system or service, shop drawings, input/output matrix, battery calculations, and notification appliance circuit voltage drop calculations, shall be submitted for approval.
10.18.1.3 Before requesting final approval of the installation, if required by the authority having jurisdiction, the installing contractor shall furnish a written statement stating that the system has been installed in accordance with approved plans and tested in accordance with the manufacturer's published instructions and the appropriate NFPA requirements.
10.18.1.4* The record of completion form, Figure 10.18.2.1.1, shall be permitted to be a part of the written statement required in 10.18.1.3. When more than one contractor has been responsible for the installation, each contractor shall complete the portions of the form for which that contractor had responsibility.
10.18.1.5 The record of completion form, Figure 10.18.2.1.1, shall be permitted to be a part of the documents that support the requirements of 10.18.2.4.
10.18.2 Completion Documents.
10.18.2.1 Preparation.
10.18.2.1.1* The preparation of a record of completion, Figure 10.18.2.1.1, shall be the responsibility of the qualified and experienced person described in 10.4.2.
10.18.2.1.2 The preparation of a record of completion, Figure 10.18.2.1.1 shall be in accordance with 10.18.2.1.2.1 through 10.18.2.1.2.8.
10.18.2.1.2.1 Parts 1 through 14 of the record of completion shall be completed after the system is installed and the installation wiring has been checked.
10.18.2.1.2.2 Parts 15 and 16 of the record of completion shall be completed after the operational acceptance tests have been completed.
10.18.2.1.2.3 A preliminary copy of the record of completion shall be given to the system owner and, if requested, to other authorities having jurisdiction after completion of the installation wiring tests.
10.18.2.1.2.4 A final copy of the record of completion shall be provided after completion of the operational acceptance tests.
10.18.2.1.2.5 One copy of the record of completion shall be stored at the fire alarm control unit or other approved location.
10.18.2.1.2.6 This copy shall be updated to reflect all system additions or modifications and maintained in a current condition at all times.
10.18.2.1.2.7 Where not stored at the main fire alarm control unit, the location of these documents shall be identified at the main fire alarm control unit.
10.18.2.1.2.8 If the documents are located in a separate enclosure or cabinet, the separate enclosure or cabinet shall be prominently labeled FIRE ALARM DOCUMENTS.
10.18.2.2 Revision. All fire alarm system modifications made after the initial installation shall be recorded on a revised version of the original record of completion.
10.18.2.2.1 All changes from the original information shall be shown.
10.18.2.2.2 The revised record of completion shall include a revision date.


Based on document review and interview, the facility failed to 1) obtain and maintain fire alarm records of system acceptance and 2) ensure all fire-warning equipment (horn-strobes) were installed according to plan design.

Findings include:

1) On 12/04/19, document review revealed the newly installed fire alarm system acceptance records were not readily available.

The Maintenance Manager explained the installing vendor did not provide the facility the system acceptance records upon completion of the project.

2) On 12/05/19, observation Resident Room 211 revealed the fire alarm horn-strobe device was not installed as it was in all other Resident Rooms.

The Maintenance Manager acknowledged the missing horn-strobe device and explained he was not aware the device had not been installed.

Note: New smoke detectors were installed within the past year. Smoke detector sensitivity testing is required within the first year of detector installation, then every two years thereafter.

National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition

19.4* Periodic Inspection and 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 then 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 personal protective equipment.
19.4.3 Full unobstructed access to the fire or combination fire/smoke damper shall be verified 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 or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered.
19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected.
19.4.10 All documentation shall be maintained and made available for review by the AHJ.
19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.


NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives, 2010 Edition
6.5 Periodic Inspection and Testing.
6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences.
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.
6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment.
6.5.4 Full unobstructed access to the damper shall be verified and corrected as required.
6.5.5 Where a fusible link is installed on a combination fire/smoke damper, the fusible link shall be removed for testing the damper for full closure simulating a fire condition per the requirements and frequencies of 19.5.4 of NFPA 80, Standard for Fire Doors and Other Opening Protectives.
6.5.6 The test shall be conducted with normal HVAC airflow.
6.5.7 The operation of the damper shall verify that there is no damper interference due to rust or bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.
6.5.8 The damper frame shall not be penetrated by any foreign objects that would affect proper fire damper operations.
6.5.9 The damper shall be verified to not be blocked from closure in any way.
6.5.10 The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature rating, and load rating.
6.5.11 All inspections and testing shall be documented indicating the location of the damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected.
6.5.12 All documentation shall be maintained by the property owner and available for review by the authority having jurisdiction.


Based on document review and interview, the facility failed to ensure fire, smoke and combination fire/smoke dampers were tested and inspected every four years.

Findings include:

On 12/04/19, the facility failed to provide evidence that fire, smoke and combination fire/smoke dampers were tested and inspected every four years.

On 12/05/19, a review of the facility architectural/mechanical plans dated May 1960, revealed there were at least nine fire, smoke and combination fire/smoke dampers that should have been installed when the building was built.

The Maintenance Manager was not aware there might be dampers in the building and was not aware of the inspection and testing requirement.

Based on document review and interview, the facility failed to provide evidence that all smoke and fire door assemblies were inspected and tested not less than annually.

Findings include:

On 12/04/19, document review revealed no evidence that indicated all smoke and fire door assemblies had been inspected as required.

The Maintenance Manager was not aware of the requirement for inspecting smoke and fire door assemblies.

Based on document review and interview, the facility failed to provide evidence that there was a documented maintenance program for their piped in medical gas and vacuum system.

Findings include:

On 12/04/19, the facility failed to provide documented evidence that there was a maintenance program for the piped in medical gas (oxygen) and vacuum systems.

The Maintenance Manager was not aware of the requirement and acknowledged there was no maintenance program for the piped in medical gas (oxygen) and vacuum systems.

National Fire Protection Association (NFPA) 99, Health Care Facilities Code (2012 Edition)
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). A low tension value means the ground pin of the attachment plug of the appliance is not making good contact with the grounding blade in the receptacle, thereby defeating the purpose of providing a low-impedance path to ground for the green ground wire of the appliance.


Based on observation and interview, the facility failed to provide evidence that electrical receptacle testing was completed as required.

Findings include:

On 12/04/19, the facility failed to provide documented evidence that electrical receptacle testing was conducted during the past year.

The Maintenance Manager was not aware of the requirement to test, inspect and document electrical receptacles in patient care areas.

Based on observation and interview, the facility failed to install a remote annunciator that was storage battery powered in a location readily observed by operating personnel.

Findings include:

On 12/05/19, observation of the Emergency Department Nurses Station revealed a generator remote annunciator device had been installed in the wall. An operational test of the annunciator was attempted by pressing the "lamp test" button. There was no response from the panel when the button was pressed.

The Maintenance Manager explained that the annunciator had been installed but not wired.