HospitalInspections.org

Based on record review and interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition.Failure to inspect/test all components connected to the fire alarm system could delay emergency services response and evacuation out of the building in the event of a fire or other emergency. This deficient practice has the potential to affect all patients, staff and visitors. The facility census was 12.

Record review of the annual fire alarm inspection dated 8/22/22 did not show inspections for the Post Indicator Valve.

During an interview on 6/27/23, the Director of Facilities Services said the Post Indicator Valve inspection was not completed on the annual fire alarm inspection.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information.

Based on record review and interview, facility staff failed to inspect two of two wet sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 12.

1) Record review on 6/27/23 failed to show the following inspections:

- quarterly inspections/testing (Table 13.1.1.2);

- monthly inspections.

During an interview on 6/27/23 at 1:56 PM, the Director of Facility Services stated he did not know the sprinkler system inspection requirements.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13, and 14 for additional information.

Based on record review and interview, the facility failed to conduct an annual load bank test for two of two emergency generators and failed to perform annual testing with the available building electrical load at a minimum of 30% of the generator nameplate rating or load bank records. The facility census was 12.

Record review on 6/27/23 of the facility generator records showed no records showing two of two emergency generators received an annual load bank test. Review showed no records that the building pulled at least 30% of the generator's nameplate's.

During an interview on 6/27/23 at 1:00 PM, the Boiler Room Operator said he is responsible for exercising the generator's. The Boiler Room Operator said that neither generator received an annual load bank test. The Boiler Room Operator said that he did not know if the building pulled at least 30 % of the generator's nameplate's.

Section 6.4.4.1.1.4 (A) of the National Fire Protection Association (NFPA 99) states: Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems systems shall be tested in accordance with NFPA 110, Standards for Emergency and Standby Power Systems, Chapter 8.

Record review on 1/30/2020 of the facility generator records did not show records of annual testing with the available building electrical load at a minimum of 30% of the generator nameplate rating or load bank records.

During an interview on 1/30/2020 at 1:00 P.M., the Corporate Director of Facilities and Materials said the facility last conducted an annual load bank test on 6/19/2018.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition states:

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.

8.4.2* Diesel generator sets in service shall be exercised at
least once monthly, for a minimum of 30 minutes, using one
of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures
as recommended by the manufacturer
(2) Under operating temperature conditions and at not less
than 30 percent of the EPS nameplate kW rating

8.4.2.1 The date and time of day for required testing shall be
decided by the owner, based on facility operations.

8.4.2.2 Equivalent loads used for testing shall be automatically
replaced with the emergency loads in case of failure of
the primary source.

8.4.2.3 Diesel-powered EPS installations that do not meet the
requirements of 8.4.2 shall be exercised monthly with the available
EPSS load and shall be exercised annually with supplemental
loads at not less than 50 percent of the EPS nameplate kW
rating for 30 continuous minutes and at not less than 75 percent
of the EPS nameplate kWrating for 1 continuous hour for a total
test duration of not less than 1.5 continuous hours.

8.3 Maintenance and Operational Testing.

8.3.1* The EPSS shall be maintained to ensure to a reasonable
degree that the system is capable of supplying service within the
time specified for the type and for the time duration specified for
the class.

8.3.2 A routine maintenance and operational testing program
shall be initiated immediately after the EPSS has passed
acceptance tests or after completion of repairs that impact the
operational reliability of the system.

8.3.2.1 The operational test shall be initiated at an ATS and
shall include testing of each EPSS component on which maintenance
or repair has been performed, including the transfer of
each automatic and manual transfer switch to the alternate
power source, for a period of not less than 30 minutes under
operating temperature.

8.3.3 A written schedule for routine maintenance and operational
testing of the EPSS shall be established.

8.3.4 A permanent record of the EPSS inspections, tests, exercising,
operation, and repairs shall be maintained and readily
available.

8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective
action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the
manufacturer

8.3.5* Transfer switches shall be subjected to a maintenance and
testing program that includes all of the following operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.3.6 Paralleling gear shall be subject to an inspection, testing,
and maintenance program that includes all of the following
operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

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 manufacturer ' s
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.

8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.

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.

8.4.6 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.

7.2.4* Minimizing the possibility of damage resulting from interruptions
of the emergency source shall be a design consideration
for EPSS equipment.

A.7.2.4 When installing the EPSS equipment and related
auxiliaries, environmental considerations should be given,
particularly with regard to the installation of the fuel tanks
and exhaust lines, or the EPS building, or both.
To protect against disruption of power in the facility, it is recommended
that the transfer switch be located as close to the load
as possible. The following are examples of external influences:
(1) Natural conditions
(a) Storms
(b) Floods
(c) Earthquakes
(d) Tornadoes
(e) Hurricanes
(f) Lightning
(g) Ice storms
(h) Wind
(i) Fire
(2) Human-caused conditions
(a) Vandalism
(b) Sabotage
(c) Other similar occurrences
(3) Material and equipment failures
For natural conditions, EPSS design should consider the
"100-year storm" flooding level or the flooding level predicted
by the Sea, Lake, and Overland Surges from Hurricanes