HospitalInspections.org

NFPA 72 National Fire Alarm and Signaling Code 2010 edition

14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.

14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3

14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obstruction 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.

14.4.5.5.3 Records shall be kept by the building owner specifying which detectors have been tested.

14.4.5.5.4 Within 5 years, each detector shall have been tested.

14.6.2.1 Records shall be retained until the next test and for 1 year thereafter.

14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:

(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number (6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

This Code was not met as evidenced by:

Based on document review and interview, the facility staff failed to provide documented evidence of sensitivity tests of smoke detectors.

The deficient practice had a potential for the smoke detectors' to not function as designed during a fire emergency.

Finding:

During the document review on 7/19/18 at 9 a.m., the evaluator noted that there was no documented evidence that the facility conducted sensitivity test of the smoke detectors.

At the same time as the document review the Facilities Manager stated that he was having support staff look for the sensitivity test. By the end of the survey no documented evidence of smoke detectors sensitivity test was provided to the evaluator.

NFPA 101 Life Safety Code 2012 Edition

33.2.3.5.3 Where an automatic sprinkler system is installed, for either total or partial building coverage, all of the following requirements shall be met:

(1) The system shall be in accordance with Section 9.7 and shall initiate the fire alarm system in accordance with 33.2.3.4.1, as modified by 33.2.3.5.3.1 through 33.2.3.5.3.6.
(2) The adequacy of the water supply shall be documented to the authority having jurisdiction.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems.

9.7.8 Record Keeping. Testing and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition

4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

4.3.5 Subsequent records shall be retained for a period of 1 year after the next inspection, test, or maintenance of that type required by the standard.

4.5.1 All components and systems shall be tested to verify that they function as intended.

5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

This Code and Standard were not met as evidenced by:

Based on document review and interview the facility staff failed to provide documented evidence the automatic fire sprinkler system was inspected and tested annually.

The deficiency had the potential to not ensure the sprinkler system is maintained to function as designed during a fire emergency.

Finding:

During the document review on 7/19/18 at 10:40 a.m., the evaluator noted that the facility was unable to produce any documented evidence of a current annual inspection and test of the facility's automatic fire sprinkler system was conducted.

During an interview at the same time as the document review the Facilities Manager stated that he was having support staff contact the sprinkler system service vendor to get a copy of the current annual fire sprinkler system inspection and test.

By the end of the survey no documented evidence of a current annual inspection and test of the sprinkler system, results, and corrections was provided to the evaluator.

NFPA 10 Standard for Portable Fire Extinguishers 2010 edition

6.1.3.1 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire.

This standard was not met as evidenced by:

Based on observation and interview, the facility failed to ensure that a fire extinguisher was conspicuously located by having the fire extinguisher signage visually and conspicuously available

Portable fire extinguishers are intended as a first line of defense to cope with fires of limited size. For the fire extinguisher to do its job, it must be conspicuously located to avoid delay in its use.

Finding:

During the Life Safety Code survey on 7/18/18 at 3:09 p.m., the evaluator noted a Fire extinguisher location sign at the laboratory wall that indicated that there was a fire extinguisher located below the sign. Closer observation revealed that there was no extinguisher located below the sign. Further observation revealed that the closest fire extinguisher to the sign was across the room on the opposite wall.

The Facility's Manager was informed of the deficiency during an interview on 7/18/18 at 3 p.m.

NFPA 110 Standard for Emergency and Standby Power Systems 2010 Edition

8.1.1 The routine maintenance and operational testing program shall be based on all of the following:
(1) Manufacturer's recommendations
(2) Instruction manuals
(3) Minimum requirements of this chapter
(4) The authority having jurisdiction

8.2.1 At least two sets of instruction manuals for all major components of the EPSS shall be supplied by the manufacturer(s) of the EPSS and shall contain the following:
(1) A detailed explanation of the operation of the system
(2) Instructions for routine maintenance
(3) Detailed instructions for repair of the EPS and other major components of the EPSS
(4) An illustrated parts list and part numbers
(5) Illustrated and schematic drawings of electrical wiring systems, including operating and safety devices, control panels, instrumentation, and annunciators

8.2.2 For Level 1 systems, instruction manuals shall be kept in a secure, convenient location, one set near the equipment, and the other set in a separate location.

This Standard was not met as evidenced by:

Based on document review and interview the facility staff failed to maintain an instruction manual for the emergency generator.

The deficient practice would not ensure that the routine maintenance and operational testing program of the EPSS would be based in part on the manufacturer's recommendations and instruction manual.

Finding:

During document review on 7/19/18 at 9 a.m., the evaluator noted that the facility could not provide the emergency power supply (generator) owner's generator manual.

During an interview at the same time as the document review the Facility's Manager stated that he was not able to find the manual.