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Based on documentation review, it was determined the hospital failed to inspect, test and maintain all components of the facility fire alarm system. Findings include:

1. On 12/07/10 at approximately 9:00 a.m., a fire alarm inspection and testing report dated 09/16/09 for the hospital was reviewed. All components of the fire alarm system are required to be inspected and tested annually (twelve (12) month intervals), therefore the fire alarm inspection for the hospital would have been due by 09/16/10. There was no documentation evidence available at the time of the survey to indicate the fire alarm system had been inspected and tested during the previous twelve (12) month period.

National Fire Protection Association (NFPA) 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-1 General.
This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

Item Activity Frequency Reference

Alarm
devices Inspection Quarterly 2-2.6

Hydraulic
nameplate Inspection Quarterly 2-2.7
Alarm
devices Test Quarterly 2-3.3

Main
drain Test Quarterly Table 9-1

This Standard is not met as evidenced by:

Based on record review, it was determined that the hospital failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25. Findings include:

1. On 12/07/10 at approximately 8:35 a.m., a review of the hospital sprinkler inspection reports was conducted. At this time, there were no evidence that a sprinkler inspection had been conducted for the first and third quarter. The sprinkler system was inspected on 06/02/10 second quarter and again on 10/12/10 fourth quarter.

National Fire Protection Association (NFPA) 10 - Standard for Portable Fire Extinguishers
Chapter 4 - Inspection, Maintenance, and Recharging
4-4* Maintenance.
4-4.4.1*
Fire extinguishers that pass the applicable 6-year requirement of 4-4.3 shall have the maintenance information recorded on a suitable metallic label or equally durable material having a minimum size of 2 in. 3 1/2 in. (5.1 cm 8.9 cm).
The new label shall be affixed to the shell by a heatless process, and any old maintenance labels shall be removed. These labels shall be of the self-destructive type when removal from a fire extinguisher is attempted. The label shall include the following information:
(a) Month and year the maintenance was performed, indicated by a perforation such as is done by a hand punch
(b) Name or initials of person performing the maintenance and name of agency performing the maintenance.
4-4.3* Six-Year Maintenance.
Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. The removal of agent from halon agent fire extinguishers shall only be done using a listed halon closed recovery system. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date.
Exception: Nonrechargeable fire extinguishers shall not be hydrostatically tested but shall be removed from service at a maximum interval of 12 years from the date of manufacture. Nonrechargeable halon agent fire extinguishers shall be disposed of in accordance with 4-3.3.3.
4-4.4.2* Verification of Service (Maintenance or Recharging).
Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged (see 4-5.5) shall have a "Verification of Service" collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch.
Exception No. 1: Fire extinguishers undergoing maintenance before January 1, 1999.
Exception No. 2: Cartridge/cylinder-operated fire extinguishers do not require a "Verification of Service" collar.

This Standard is not met as evidenced by:

Based on observation, the hospital failed to maintain and test Fire extinguishers in accordance with NFPA 10. Findings include:

1. On 12/07/10 at approximately 10:45 a.m., an inspection of the hospital fire extinguishers was conducted. At this time, two (2) fire extinguishers located in the snack bar were observed with six (6) year maintenance date and hydrostatic test not complaint. Fire extinguisher #41 model date 2003 was past due six (6) year maintenance and the K guard fire extinguisher model date 2004 was past due five (5) year hydrostatic test.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operation
Chapter 7 Fire - Extinguishing Equipment
7-2 Types of Equipment
7-2.2.1
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer"s instructions, and the following standards where applicable.
(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems
NFPA 17 Standard for Dry Chemical Systems 1998 Edition
Chapter 9 Inspection, Maintenance, and Recharging
9-3.1*
At least semiannually, maintenance shall be conducted in accordance with the manufacturer's listed installation and maintenance manual.

This Standard is not met as evidenced by:

Based on review of documentation, it was determined the facility failed to maintain and inspect the range hood extinguishing system as required by NFPA 96.
Findings include:

1. On 12/07/10 at approximately 1:35 p.m., the hospital snack bar range hood extinguishing system reports for the previous twelve (12) month period were reviewed. At this time, inspection dates for 06/07/10 and 09/22/09 were listed. There was no evidence of an inspection conducted during the second half September 2010. Range hood extinguishing systems are required to be inspected and tested at six (6) month intervals.

9.4.6 Elevator Testing.
Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators.

This Standard is not met as evidenced by:

Based on review of facility documentation, it was determined the hospital failed to maintain elevators compliant. Findings include:

1. On 12/07/10 at approximately 8:15 a.m., the hospital elevator inspection reports were reviewed. The inspection reports dated 09/03/10 revealed that the following elevator cars were in need of repair and would not be acceptable as compliant for certification. (ED4371 #4 switchboard) (ED4369 #1 Mailroom) (ED4373 #5 Snack bar) (ED4375 #7 C-2) (ED4376 #2 Building H Shop) therefore the inspection certification could not be completed until repairs were completed.