HospitalInspections.org

Reference: National Fire Protection Association (NFPA) 25

13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised.

13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification


Based on record review and interview, the facility failed to ensure the automatic sprinkler system locked and or supervised valves were inspected monthly per NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems). Not inspecting valves on the required frequency could result in a valve that is not in its normal position, accessible, sealed, locked or supervised, leaking, and not properly identified. This failed practice could result in the automatic sprinkler system becoming inoperable or unreliable which, in the event of fire, presents the risk of potential harm to all patients at the facility. The findings are:



A. On 08/27/19 at 10:20 am, record review revealed no documentation of monthly sprinkler system valve inspections and no inspection log posted in the mechanical room.

B. On 08/27/19 at 10:25 am, during interview, the Plant Operations Manager stated that he was not aware of the requirement.

NFPA 101 Life Safety Code (2012 Edition)

19.5 Building Services
19.5.1 Utilities
19.5.1.1 Utilities shall comply with the provisions of Section 9.1

9.1 Utilities
9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110 Standard for Emergency and Standby Power Systems (2010 Edition)

8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards. (American Section of the International Association for Testing Materials).


Based on interview and record review of Generator log and maintenance documentation, the facility failed to ensure a fuel quality test was conducted annually on the diesel powered generator, as per requirements of NFPA 110 and ASTM (American Section of the International Association for Testing Materials). Not conducting annual fuel quality tests, as required, for diesel powered generators could result in the failure of the Emergency Generator to supply power to the facility in the event of a main power outage. This failed practice presents a risk of injury, by the lack of emergency stand-by power to all patients at the facility. The findings are:

A. On 08/27/19 at 11:15 am, record review of the diesel fuel powered Emergency Generator maintenance log revealed there was no documentation indicating a fuel quality test had been conducted within the last 12 months.

B. On 08/27/19 at 11:20 am, during interview, the Plant Operations Manager stated he was not aware of the fuel quality test requirement.