HospitalInspections.org

Based on observation and interview, the facility failed to maintain their building free of penetrations as evidenced by penetrations in a storage room. This could lead to smoke and fire penetrating into other areas of the facility and affected one of three smoke compartments.

NFPA 101 Life Safety Code, 2000 Edition
8.2.4.4.2 Openings located at points where smoke partitions meet the outside walls, other smoke partitions, smoke barriers, or fire barriers of a building shall meet one of the following conditions:
(1) They shall be filled with a material that is capable of limiting the transfer of smoke.
(2) They shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Facilities Manager on 9/9/14, the facility's walls and ceilings were observed.

At 2:23 p.m., in the Custodial Closet next to the Shower Room, a 22-inch by 46-inch penetration was observed in the wall next to the shower. When interviewed, the Facilities Manager stated that the penetration was due to a water leak in the shower and that repairs were put in an overall project to repair all showers and tile. A temporary repair was completed.

Based on observation, document review, and interview, the facility failed to test its battery back-up emergency lighting unit. This was evidenced by a lack of documentation provided for testing the battery-powered task lighting at the generator set location. This finding affected three of three smoke compartments within the facility and could potentially result in the generator location being unlit in the event of a power outage if the generator were to fail to start.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour, record review, and interview with the Facilities Manager on 9/10/14, the generator location was observed.


At 11:15 a.m., No emergency lighting was observed in the Generator Room. A county maintenance engineer was onsite. When interviewed, the county maintenance engineer stated that the lighting units (fluorescent type) had a 90 minute battery back-up in the ballast and that they could also use headlamps if needed.
No documentation was available indicating that the battery back-up lights had been tested for 30 second monthly or 90 minutes annually.

Based on interview and document review, the facility failed to conduct fire drills at least quarterly, on each shift, as evidenced by one of twelve missing fire drills. This could lead to staff not understanding the evacuation procedures in the event of an emergency and affected three of three smoke compartments.

Findings:

During document review with Facilities Manager on 9/10/14, the fire drill records were reviewed.

1. At 9:15 a.m., one out of twelve fire drill records were missing for the NOC shift in the 2nd quarter of 2014. When interviewed, staff acknowledged the missing fire drill.

Based on observation and interview, the facility failed to maintain its Fire Alarm System (FAS). This was evidenced by the FAS failing to activate audible alarms during testing and by the inability to reset the FAS during testing. This could lead to a delay in notification to residents and staff in the event of an emergency and affected three of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
19.3.4.2* Initiation. Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems.
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.8.1* All means of interconnecting equipment, devices, and appliances and wiring connections shall be monitored for the integrity of the interconnecting conductors or equivalent path so that the occurrence of a single open or a single ground-fault condition in the installation conductors or other signaling channels and their restoration to normal shall be automatically indicated within 200 seconds.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.

Findings:

During fire alarm system testing with the Facilities Manager and fire alarm Vendor on 9/10/14, the fire alarm system was tested.

At 2:26 p.m., a smoke detector was activated. The smoke detector on the 1st floor activated the fire alarm system (FAS) and the signal was received at the fire alarm control panel (FACP). There were no audible alarms in the building upon activation of the FAS. A burning smell was detected at the FACP. The fire alarm vendor/technician stated that the charger board that charges the panel batteries had shorted out. The vendor stated that the rest of the FACP was okay but that it could not be reset.
At 3:19 p.m., after the charger board was replaced and the FAS was reset, a waterflow device was tested with no problems.
At 3:26 p.m., a smoke detector in the Employee Lounge was tested. The smoke detector activated the FAS, but the charger board shorted out again. The fire alarm vendor immediately called another technician to come onsite to help troubleshoot the problem and to bring another charger board. Facility Staff stated that if the FAS was not functioning within 4 hours, a fire watch would be implemented.
The FAS was fully functional at 5 p.m. The facility faxed the vendor report to District Office.

Based on document review and interview, the facility failed to maintain their smoke detectors, as evidenced by missing documentation for smoke detector sensitivity testing. This could result in the increased risk of a smoke detector malfunctioning and affected three of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.2* Initiation. Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems.
Exception No. 1: Manual fire alarm boxes in patient sleeping areas shall not be required at exits if located at all nurses ' control stations or other continuously attended staff location, provided that such manual fire alarm boxes are visible and continuously accessible and that travel distances required by 9.6.2.4 are not exceeded.
Exception No. 2: Fixed extinguishing systems protecting commercial cooking equipment in kitchens that are protected by a complete automatic sprinkler system shall not be required to initiate the fire alarm system.
Exception No. 3: Detectors required by the exceptions to 19.7.5.2 and 19.7.5.3.
9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation
9.6.2.8 Where a complete smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all occupiable areas, common areas, and work spaces in those environments suitable for proper smoke detector operation.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity
range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review with the Facilities Manager on 9/10/14, the records for the smoke detector sensitivity testing were requested.

At 9:47 a.m., no documentation was provided showing that the smoke detectors were tested for sensitivity. The quarterly and annual reports indicated that the smoke detectors were tested for functionality, but not for sensitivity. The documentation did not list the smoke detectors individually with their sensitivity results. When interviewed, the Facilities Manager acknowledged the missing sensitivity testing, and thought the vendor was testing the smoke detectors for sensitivity.

Based on observation, the facility failed to maintain their portable fire extinguishers as evidenced by no signage or markings indicating the location of the portable fire extinguishers. This could result in a delay in access to the fire extinguishers during a fire emergency and affected one of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction
cannot be completely avoided, means shall be provided to indicate the location.

Findings:

During a tour of the facility with the Facilities Manager on 9/9/14, the portable fire extinguishers were observed.

At 3:05 p.m., the two portable fire extinguishers were observed to be stored in secure locations in the Staff Lounge and Nurses Station. Signs were located in the fire hose cabinets in the corridors that indicated the location of the fire extinguishers. There were no signs or markings at the entrance of the Staff Lounge or Nurses directing staff to the portable fire extinguishers that were stored inside. When interviewed, the Facilities Manager acknowledged the missing signage and stated that they were not aware of the requirement.

Based on record review and interview, the facility failed to maintain their kitchen exhaust system. This was evidenced by records showing that the system was not serviced every 6 months. This could lead to a grease buildup increasing risk of a fire and affected one of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception:* Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition

Table 8-3.1 Exhaust System Inspection Schedule


Systems serving moderate-volume cooking - Semiannually

8-2* Inspection. An inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.
8-2.1 All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, shall be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures. In addition to these requirements, the specific inspection requirements of the applicable NFPA standard shall also be followed.
8-2.2 Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper operation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer's recommendations.
8-2.3 If required, certificates of inspection and maintenance shall be forwarded to the authority having jurisdiction.

Findings:

During document review and interview with the Facilities Manager on 9/10/14, the maintenance records for kitchen exhaust system were requested.

At 9:45 a.m., records provided indicated that the exhaust system was not cleaned every six months. The cleanings were performed on 5/28/14 and 8/27/13. When interviewed, the Facilities Manager confirmed the finding.

Based on record review and interview, the facility failed to maintain its emergency generator, as evidenced by the failure to perform monthly 30 minute full load tests and weekly visual inspections. This could result in the failure of the emergency generator and affected three of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
5-3 Lighting.
5-3.1 The level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
6-3 Maintenance and Operational Testing.
6-3.4 A written record for the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer.
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During record review and interview with the Facilities Manager on 9/10/14, the generator maintenance records were reviewed.

At 9:29 a.m., the generator testing records indicated that the diesel generator was tested weekly at 15 minute intervals under load. The records did not show any weekly visual inspections. When interviewed, the Facilities Manager confirmed the weekly 15 minute tests and stated that the county maintenance personnel were responsible for the inspection and testing of the generator.

Based on observation, interview, and record review, the facility failed to maintain their electrical wiring and equipment as evidenced by the use of power strips. This was also evidenced by no current records provided for receptacle tension and polarity testing for patient care areas. This could lead to an increased risk for an electrical fire and affected three of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
NFPA 70 National Electric Code, 1999 Edition
Section 400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

NFPA 99, 1999 edition
3-3.3.3 Receptacle Testing in Patient Care Areas.
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).
3-3.4.2.3(a) Testing Interval for Receptacles in Patient Care Areas.
1. Testing shall be performed after initial installation, replacement, or servicing of the device.
2. Additional testing shall be performed at intervals defined by documented performance data.
Exception: Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months.
3-3.4.3.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, this record shall contain the date, the rooms or areas tested, and an indication of which items have met or have failed to meet the performance requirements of this chapter.

Findings:

During a tour of the facility with the Facilities Manager on 9/9/14, the electrical wiring and equipment were observed.

1. At 2:27 p.m. in Room 210, in the Doctor's Office, a fan was plugged into a surge protector.

2. At 2:46 p.m. in the Medication Room, a surge protector with computer equipment plugged into it was suspended in air.

During record review with the Facilities Manager on 9/10/14, the records for the tension and polarity testing were requested.

At 9:43 a.m., records provided for receptacle tension and polarity testing were dated 3/25/13. No current records for any testing were found. When interviewed, the Facilities Manager acknowledged that no current testing records were available.

Based on observation and interview, the facility failed to maintain their building free of penetrations as evidenced by penetrations in a storage room. This could lead to smoke and fire penetrating into other areas of the facility and affected one of three smoke compartments.

NFPA 101 Life Safety Code, 2000 Edition
8.2.4.4.2 Openings located at points where smoke partitions meet the outside walls, other smoke partitions, smoke barriers, or fire barriers of a building shall meet one of the following conditions:
(1) They shall be filled with a material that is capable of limiting the transfer of smoke.
(2) They shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Facilities Manager on 9/9/14, the facility's walls and ceilings were observed.

At 2:23 p.m., in the Custodial Closet next to the Shower Room, a 22-inch by 46-inch penetration was observed in the wall next to the shower. When interviewed, the Facilities Manager stated that the penetration was due to a water leak in the shower and that repairs were put in an overall project to repair all showers and tile. A temporary repair was completed.

Based on observation, document review, and interview, the facility failed to test its battery back-up emergency lighting unit. This was evidenced by a lack of documentation provided for testing the battery-powered task lighting at the generator set location. This finding affected three of three smoke compartments within the facility and could potentially result in the generator location being unlit in the event of a power outage if the generator were to fail to start.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour, record review, and interview with the Facilities Manager on 9/10/14, the generator location was observed.


At 11:15 a.m., No emergency lighting was observed in the Generator Room. A county maintenance engineer was onsite. When interviewed, the county maintenance engineer stated that the lighting units (fluorescent type) had a 90 minute battery back-up in the ballast and that they could also use headlamps if needed.
No documentation was available indicating that the battery back-up lights had been tested for 30 second monthly or 90 minutes annually.

Based on interview and document review, the facility failed to conduct fire drills at least quarterly, on each shift, as evidenced by one of twelve missing fire drills. This could lead to staff not understanding the evacuation procedures in the event of an emergency and affected three of three smoke compartments.

Findings:

During document review with Facilities Manager on 9/10/14, the fire drill records were reviewed.

1. At 9:15 a.m., one out of twelve fire drill records were missing for the NOC shift in the 2nd quarter of 2014. When interviewed, staff acknowledged the missing fire drill.

Based on observation and interview, the facility failed to maintain its Fire Alarm System (FAS). This was evidenced by the FAS failing to activate audible alarms during testing and by the inability to reset the FAS during testing. This could lead to a delay in notification to residents and staff in the event of an emergency and affected three of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
19.3.4.2* Initiation. Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems.
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.8.1* All means of interconnecting equipment, devices, and appliances and wiring connections shall be monitored for the integrity of the interconnecting conductors or equivalent path so that the occurrence of a single open or a single ground-fault condition in the installation conductors or other signaling channels and their restoration to normal shall be automatically indicated within 200 seconds.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.

Findings:

During fire alarm system testing with the Facilities Manager and fire alarm Vendor on 9/10/14, the fire alarm system was tested.

At 2:26 p.m., a smoke detector was activated. The smoke detector on the 1st floor activated the fire alarm system (FAS) and the signal was received at the fire alarm control panel (FACP). There were no audible alarms in the building upon activation of the FAS. A burning smell was detected at the FACP. The fire alarm vendor/technician stated that the charger board that charges the panel batteries had shorted out. The vendor stated that the rest of the FACP was okay but that it could not be reset.
At 3:19 p.m., after the charger board was replaced and the FAS was reset, a waterflow device was tested with no problems.
At 3:26 p.m., a smoke detector in the Employee Lounge was tested. The smoke detector activated the FAS, but the charger board shorted out again. The fire alarm vendor immediately called another technician to come onsite to help troubleshoot the problem and to bring another charger board. Facility Staff stated that if the FAS was not functioning within 4 hours, a fire watch would be implemented.
The FAS was fully functional at 5 p.m. The facility faxed the vendor report to District Office.

Based on document review and interview, the facility failed to maintain their smoke detectors, as evidenced by missing documentation for smoke detector sensitivity testing. This could result in the increased risk of a smoke detector malfunctioning and affected three of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.2* Initiation. Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems.
Exception No. 1: Manual fire alarm boxes in patient sleeping areas shall not be required at exits if located at all nurses ' control stations or other continuously attended staff location, provided that such manual fire alarm boxes are visible and continuously accessible and that travel distances required by 9.6.2.4 are not exceeded.
Exception No. 2: Fixed extinguishing systems protecting commercial cooking equipment in kitchens that are protected by a complete automatic sprinkler system shall not be required to initiate the fire alarm system.
Exception No. 3: Detectors required by the exceptions to 19.7.5.2 and 19.7.5.3.
9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation
9.6.2.8 Where a complete smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all occupiable areas, common areas, and work spaces in those environments suitable for proper smoke detector operation.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity
range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review with the Facilities Manager on 9/10/14, the records for the smoke detector sensitivity testing were requested.

At 9:47 a.m., no documentation was provided showing that the smoke detectors were tested for sensitivity. The quarterly and annual reports indicated that the smoke detectors were tested for functionality, but not for sensitivity. The documentation did not list the smoke detectors individually with their sensitivity results. When interviewed, the Facilities Manager acknowledged the missing sensitivity testing, and thought the vendor was testing the smoke detectors for sensitivity.

Based on observation, the facility failed to maintain their portable fire extinguishers as evidenced by no signage or markings indicating the location of the portable fire extinguishers. This could result in a delay in access to the fire extinguishers during a fire emergency and affected one of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction
cannot be completely avoided, means shall be provided to indicate the location.

Findings:

During a tour of the facility with the Facilities Manager on 9/9/14, the portable fire extinguishers were observed.

At 3:05 p.m., the two portable fire extinguishers were observed to be stored in secure locations in the Staff Lounge and Nurses Station. Signs were located in the fire hose cabinets in the corridors that indicated the location of the fire extinguishers. There were no signs or markings at the entrance of the Staff Lounge or Nurses directing staff to the portable fire extinguishers that were stored inside. When interviewed, the Facilities Manager acknowledged the missing signage and stated that they were not aware of the requirement.

Based on record review and interview, the facility failed to maintain their kitchen exhaust system. This was evidenced by records showing that the system was not serviced every 6 months. This could lead to a grease buildup increasing risk of a fire and affected one of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception:* Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition

Table 8-3.1 Exhaust System Inspection Schedule


Systems serving moderate-volume cooking - Semiannually

8-2* Inspection. An inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.
8-2.1 All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, shall be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures. In addition to these requirements, the specific inspection requirements of the applicable NFPA standard shall also be followed.
8-2.2 Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper operation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer's recommendations.
8-2.3 If required, certificates of inspection and maintenance shall be forwarded to the authority having jurisdiction.

Findings:

During document review and interview with the Facilities Manager on 9/10/14, the maintenance records for kitchen exhaust system were requested.

At 9:45 a.m., records provided indicated that the exhaust system was not cleaned every six months. The cleanings were performed on 5/28/14 and 8/27/13. When interviewed, the Facilities Manager confirmed the finding.

Based on record review and interview, the facility failed to maintain its emergency generator, as evidenced by the failure to perform monthly 30 minute full load tests and weekly visual inspections. This could result in the failure of the emergency generator and affected three of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
5-3 Lighting.
5-3.1 The level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
6-3 Maintenance and Operational Testing.
6-3.4 A written record for the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer.
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During record review and interview with the Facilities Manager on 9/10/14, the generator maintenance records were reviewed.

At 9:29 a.m., the generator testing records indicated that the diesel generator was tested weekly at 15 minute intervals under load. The records did not show any weekly visual inspections. When interviewed, the Facilities Manager confirmed the weekly 15 minute tests and stated that the county maintenance personnel were responsible for the inspection and testing of the generator.

Based on observation, interview, and record review, the facility failed to maintain their electrical wiring and equipment as evidenced by the use of power strips. This was also evidenced by no current records provided for receptacle tension and polarity testing for patient care areas. This could lead to an increased risk for an electrical fire and affected three of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
NFPA 70 National Electric Code, 1999 Edition
Section 400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

NFPA 99, 1999 edition
3-3.3.3 Receptacle Testing in Patient Care Areas.
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).
3-3.4.2.3(a) Testing Interval for Receptacles in Patient Care Areas.
1. Testing shall be performed after initial installation, replacement, or servicing of the device.
2. Additional testing shall be performed at intervals defined by documented performance data.
Exception: Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months.
3-3.4.3.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, this record shall contain the date, the rooms or areas tested, and an indication of which items have met or have failed to meet the performance requirements of this chapter.

Findings:

During a tour of the facility with the Facilities Manager on 9/9/14, the electrical wiring and equipment were observed.

1. At 2:27 p.m. in Room 210, in the Doctor's Office, a fan was plugged into a surge protector.

2. At 2:46 p.m. in the Medication Room, a surge protector with computer equipment plugged into it was suspended in air.

During record review with the Facilities Manager on 9/10/14, the records for the tension and polarity testing were requested.

At 9:43 a.m., records provided for receptacle tension and polarity testing were dated 3/25/13. No current records for any testing were found. When interviewed, the Facilities Manager acknowledged that no current testing records were available.