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NFPA 72: 10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

NFPA 72:10.4.1.2 State or local licensure regulations shall be followed to determine qualified personnel. Depending on state or local licensure regulations, qualified personnel shall include, but not be limited to, one or more of the following: (1) Personnel who are registered, licensed, or certified by a state or local authority.

LAC 55:V:3033. Fixed Fire Suppression and Fire Detection and Alarm Systems and Equipment... B. All existing required fixed fire suppression systems including kitchen, pre-engineered and engineered systems, and fire detection and alarm systems shall be certified, hydrostatically tested, inspected, integrated, maintained and serviced in an operational condition in accordance with the manufacturer's installation manuals, specifications, and per the inspection, testing and maintenance chapters of the applicable codes and standards adopted in L.A.C.55:V.103 or noted in these rules.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect ten of ten patients.

Findings:

During the facility tour on September 1, 2022 between the hours of 12:30 p.m. to 3:00 p.m. and on September 2, 2022 between the hours of 2:45 p.m. to 5:15 p.m. the fire alarm system was yellow tagged by a licensed company on August 24, 2022 due to a external trouble alarm believed to be related to the phone line supervision being inactive.

The interview with the Administrator revealed the facility was aware that the fire alarm supervision was lacking due to the phone line service being disconnected. The administrator was in the process of of restoring the fire alarm analog phone line by arranging a meeting to discuss the previous phone company accounts with the phone company on Monday September 5, 2022.

NFPA 101:9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 101:19.3.4.3.2 Emergency Forces Notification.


NFPA 101:19.3.4.3.2.1 Fire department notification shall be accomplished in accordance with 9.6.4.

NFPA 101:9.6.4 Emergency Forces Notification.

NFPA 101:9.6.4.1 Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency.

NFPA 101:9.6.4.2 Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code:
(1) Auxiliary fire alarm system
(2) Central station fire alarm system
(3) Proprietary supervising station fire alarm system
(4) Remote supervising station fire alarm system

NFPA 101:9.6.4.3 For existing installations where none of the means of notification specified in 9.6.4.2(1) through (4) are available, an approved plan for notification of the municipal fire department shall be permitted.

Based on visual observation the facility failed to assure that the automatic sprinkler system had supervised valves that will sound a local alarm if closed. A direct result, of the fire alarm system being notified of the emergency, is protection of life and property. This deficiency has the potential to affect ten of ten patients.

Findings:

During the facility tour on September 1, 2022 between the hours of 12:30 p.m. to 3:00 p.m. and on September 2, 2022 between the hours of 2:45 p.m. to 5:15 p.m. the fire alarm system is lacking supervision to a remote station due to the fire alarm analog phone service being inactivated by the phone company.

The interview with the Administrator revealed the facility was aware that the fire alarm supervision was lacking due to the phone line service being disconnected. The administrator was in the process of of restoring the fire alarm analog phone line by arranging a meeting to discuss the previous phone company accounts with the phone company on Monday September 5, 2022.

L.R.S. 40:1578.6 (C)
This inspector deems that a serious life hazard exists due to the lack of a require operative (fire alarm system/sprinkler system). Therefore, the 2012 edition of the life safety code shall be implemented as per the following:

NFPA 101:9.6.1.6 (F.A.) K 346 OR NFPA 25:15.5.2 (A.S.) K 354
"Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period or a sprinkler system is out of service for more than 10 hours in a 24-hour period, the authority having jurisdiction shall be notified. The facility shall be evacuated or an approved fire watch shall be provided."
Facility shall implement a fire watch in accordance with State Fire Marshal Guidelines, a copy of said guidelines given to Assistant Administrator and said fire watch shall remain in effect until the system is back in service and an inspection has been conducted by this office.

NFPA 101:9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 101:19.3.4.3.2 Emergency Forces Notification.


NFPA 101:19.3.4.3.2.1 Fire department notification shall be accomplished in accordance with 9.6.4.

NFPA 101:9.6.4 Emergency Forces Notification.

NFPA 101:9.6.4.1 Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency.

NFPA 101:9.6.4.2 Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code:
(1) Auxiliary fire alarm system
(2) Central station fire alarm system
(3) Proprietary supervising station fire alarm system
(4) Remote supervising station fire alarm system

NFPA 101:9.6.4.3 For existing installations where none of the means of notification specified in 9.6.4.2(1) through (4) are available, an approved plan for notification of the municipal fire department shall be permitted.

Based on visual observation and documentation the facility failed to assure that the complete, supervised, automatic sprinkler system was functional without interruption. In the event of failure, an approved fire watch shall be implemented if the facility is not fully evacuated until the system is returned to service. The fire alarm system offers advanced warning in a fire/smoke emergency. This deficiency could potentially affect ten of ten patients.


Findings:

During the facility tour on September 1, 2022 between the hours of 12:30 p.m. to 3:00 p.m. and on September 2, 2022 between the hours of 2:45 p.m. to 5:15 p.m. the fire alarm system is lacking supervision to a remote station due to the fire alarm analog phone service being inactivated by the phone company.

The interview with the Administrator revealed the facility was aware that the fire alarm supervision was lacking due to the phone line service being disconnected. The administrator was in the process of of restoring the fire alarm analog phone line by arranging a meeting to discuss the previous phone company accounts with the phone company on Monday September 5, 2022. The LSC Specialist discussed with the Assistant Administrator and furnished a copy of the fire watch guidelines and logs to be completed while the Hospital is occupied. The LSC Specialist informed the Assistant Administrator to notify the local fire department that their fire alarm lacking supervision and a fire watch is being conducted to assign a designated person to contact the fire department in the event of a fire emergency.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. Improper wiring creates a high risk of injury and/or death. The deficiency has the potential to affect ten of ten patients.

Findings:

During the facility tour on September 1, 2022 between the hours of 12:30 p.m. to 3:00 p.m. and on September 2, 2022 between the hours of 2:45 p.m. to 5:15 p.m. the patient room identified as number three did have one active electrical receptacle being used to supply power via trip lite 1363A/ UL- 60601-1. However, the other two electrical receptacle were not functioning. The clean supply room suspended mounted light fixture lens had a large water stain indicating the roof had leaked rain water within the electrical suspended ceiling mounted light fixture.

NFPA 101: 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

LAC 55:V:105. Required Inspections of Wiring, Gas Piping and Fire Extinguishers
D. In order to assure that the electrical wiring in any structure or movable will not cause a fire or explosion, the electrical wiring in any structure, watercraft or movable shall be inspected and, if necessary, repaired by a licensed electrical contractor in accordance with the National Electrical Code
E. In order to assure that any structure, watercraft or movable is safe from hazards caused by gas piping, all gas piping shall be inspected and, if necessary, repaired by a licensed plumber or mechanical contractor in accordance with the applicable National Fuel Gas Code of the National Fire Protection Association and the provisions of the Louisiana Revised Statutes.
F. The inspections required by this regulation for electrical wiring and gas piping shall be made at the time of the initial installation and thereafter as required based upon a visual inspection by the fire marshal or his designated representative.

The interview with the Assistant Administrator discussed revealed the facility was unaware two of three electrical receptacles in patient room number three being inoperable. LSC Specialist discussed providing a electrical certificate from a licensed electrician on a company letterhead with the licensed electrician's license number and signature. The letter shall indicate all the electrical wiring within the facility had either been repaired, replaced or inspected and appears to be in accordance with the NEC /NFPA 70.