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Based on observations and confirmed by staff interview the facility failed to ensure compliance with Chapter 19 "Existing Health Care Occupancies" of the 2012 Edition of NFPA 101 "Life Safety Code".
Chapter 19 Section 19.3.1 "Protection of Vertical Openings" states any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8.
Chapter 19 Section 19.3.1.1 states where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

Findings Include:

While conducting the survey on 3/22/18 and 3/23/18, it was revealed that the main stairway that provides access between the first and second floors, located at the main entrance by the front desk, is enclosed with less than one hour fire rated construction.

As a result of the deficiency the facility is found to be non-compliant with Chapter 19 Section 19.3.1.1

The findings were confirmed by the hospital administration during the exit conference.

NOTE: This item does not meet NFPA 101 Life Safety Code, 2012 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2013 edition where such equivalency is requested and approved.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is tested and inspected as required.

NFPA section 39.3.4.1 states that fire alarm system in accordance with Section 9.6 shall be provided in all business occupancies where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

NFPA section 9.6.1.3 states that a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA #72 (National Fire Alarm Code) section 14.2.2.1 states the property or building or system owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.

NFPA 72 section 14.2.2.2 states the delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

NFPA #72, Table 14.4.5 (6) requires systems with sealed batteries to have the battery charger tested annually, replace the battery every 5 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

Table 14.4.5 (22) requires off premise transmission testing to be performed annually.

Section 14.4.5.3.1 states sensitivity shall be checked within 1 year after installation.
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Section 14.4.5.3.2 states sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.

Section 14.4.5.3.3 states 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 obscuration 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.

THE FINDINGS INCLUDE:

During the morning hours of 05/23/18 while reviewing the testing/inspection records of the fire alarm system, the following items were observed regarding testing/inspection of the system which is provided at this location:

1) There is no documentation that the off-premise testing is performed as the line item pertaining to this test was observed to be blank on the test/inspection forms provided.

2) There is no documentation that the battery and battery charger testing is performed as the line items pertaining to these tests were observed to be blank on the test/inspection forms provided.

3) There is no documentation that the sensitivity testing is performed as there are no line items pertaining to this type of test on the test/inspection forms provided.

Note: The fire alarm system is currently inspected/tested on an annual basis with the last test being performed on 2/14/17. In addition to only having annual inspections/tests, the form provided was observed to be mainly blank for all of the various components of the system.

As a result, the facility failed to comply with NFPA 72 for the required testing of the fire alarm system and all components.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff, the facility failed to ensure that sprinkler systems are properly maintained as required.

Section 39.1.1.3 states the provisions of Chapter 4, General, shall apply.

Section 4.1.1 states a goal of this code is to provide an environment for the occupants that is reasonably safe from fire by the following means:
(1) Protection of occupants not intimate with the initial fire development.
(2) Improvement of the survivability of occupants intimate with the initial fire development.

Section 4.2.3 states systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

Section 4.3.1 states 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.

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

Section 4.3.3 states records shall be maintained by the property owner.

Section 4.6.12.4 states any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

NFPA #25 (Inspection and Testing of Fire Protection Systems) section 4.1.1 states the property owner or designated representative shall be responsible for properly maintaining a water based fire protection system.

Section 4.1.1.1.1 states inspection, testing, maintenance, and impairment shall be implemented in accordance with procedures meeting those established in this document and in accordance with the manufacturer's instructions.

Section 4.1.1.2 states inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.

Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard.

Section 4.1.4.2 states corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

Section 4.5.1 states all components and systems shall be tested to verify that they function as intended.

Section 5.2.4.2 states gauges on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained.

Section 13.2.6.2 states vane-type and pressure switch-type waterflow devices shall be tested semi-annually.

Section 13.2.7.2 states gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.

Section 13.2.7.3 states gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

Section 13.4.4.2.1 states the priming water level shall be tested quarterly.

Section 13.4.4.2.6 states low air pressure alarms, if provided, shall be tested quarterly in accordance with the manufacturer ' s instructions.

NFPA 13 section 7.1.1.2 states pressure gauges shall be installed above and below each alarm check valve or system riser check valve where such devices are present.

THE FINDINGS INCLUDE:

During the morning hours of 05/23/18 while reviewing the testing/inspection records of the sprinkler system and a facility walk through, the following items were observed regarding testing/inspection of the system which is provided at this location:

1) The facility does not observe and record weekly air and water pressures of the dry pipe sprinkler system.

2) The sprinkler system was observed to be only tested/inspected on an annual basis last performed on 8/7/17. As noted above, various components are required to have quarterly and/or semi-annual testing performed.

3) The sprinkler gauges on the system are dated 2007. There is no documentation that the gauges have been tested for the correct calibration.

4) There is no pressure gauge provided on the sprinkler system before the back flow device.

Note: The sprinkler system is currently inspected/tested on an annual basis with the last test being performed on 8/7/17.

As a result of the above findings, the facility failed to comply with section 39.1.1.3 requiring systems to be maintained in a proper operating condition.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.