Volume 2025 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
■ An annual inspection of visual devices and of interconnected equipment relays was not documented. ■ The hospital did not provide evidence that the following devices had been tested as required: ٝ Waterflow switches: Semi-annual testing. ٝ Supervisory initiating devices: Quarterly testing for fire pump and semi-annual testing for valve tamper switches. ٝ Interconnected equipment: Annual testing for magnetic hold-open, air handler shut-down, elevator recall, magnetic locks/strikes, smoke dampers, and overhead rolling fire doors. ٝ Control panel batteries: Semi-annual load voltage test. ■ The inventory of initiating devices from the 2023 report to the 2024 report differed by 20 without any explanation of the discrepancy. The inventory of notification devices from the 2023 report to the 2024 report differed by 13 without any explanation. ■ Smoke detector testing was completed annually. Semi-annual testing and inspection is required. Fire pump supervisory signal testing was completed annually. Quarterly testing is required. Compliance tips for:
14.03.01 (CAH) 13.03.01 14.03.02 (CAH) 13.03.02 Frequency of the citation: 14.03.01 56%; 13.03.01 45% | 14.03.02 67%; 13.03.02 35% Water-based fire protection system: Testing and inspection Water-based fire protection system: Installation and maintenance
Overview of the requirement: Hospitals constructed (or with areas renovated) since the adoption of the 1991 Life Safety Code require water-based sprinkler systems. Once installed, systems must be maintained and tested to ensure compliance with the original installation requirements. Comment on deficiencies: Compliance is assessed through observation and interview. Surveyors noted issues with:
■ Sprinkler coverage and installation. ■ Sprinkler obstructions and clearance. ■ Sprinkler condition and maintenance. ■ Inspection, testing, and documentation. ■ System signage and identification.
Fire alarm systems include a large number of components that work in coordination to create a detection and notification system. The initial installation of the components must meet Life Safety Code standards and, once installed, the system must be maintained to the original installation requirements. Individual components are tested per NFPA 72 requirements. ■ Review smoke detector locations relative to other features to ensure compliant placement. ■ Inventory all basic devices with their secondary components for testing. ■ Develop a testing calendar reflecting timing defined by NFPA. Develop logs to document testing and include follow-up actions for testing failures. ■ Recognize that any deficiency with the fire alarm system that cannot be corrected on the same day must prompt an ALSM assessment.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Examples of ACHC Surveyor findings: ■ Electrical rooms in surgical telemetry and medical telemetry units did not have a required sprinkler head. ■ Cables are supported by the sprinkler system piping (above ceiling level) near the physician's workroom in the cancer center/in the fifth floor corridor near elevator 3/at the entrance to the pediatric unit. ■ Inside CT rooms, a total of nine fire sprinkler head escutcheons are painted over. ■ The sprinkler heads in the kitchen of the behavioral health unit were coated with grease and dust that would impede their effectiveness. ٝ Boxes were observed stored less than 18 inches from the sprinkler head. ■ The facility self-reported to be fully sprinklered. There was no sprinkler coverage inside the CCU dictation room.
Nerd Trailblazers (prepare the path for others)
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