Mar 07 2017

State Agency Validation Survey

Category: CMS,Questions and AnswersBKeyes @ 12:00 am

Q: I recently had a state validation inspection and wanted to get some clarification on a few their findings:

“K 353: The facility failed to provide complete visual observation checklist during the weekly churn test. Not in accordance with NFPA 25, 2011 edition Section”

I have been doing a weekly churn test for the past two years (now it will be monthly) the information on the form includes discharge pressure and how long it took for the pump to kick on after the main drain was open. My question is what else is required and what does a visual observation checklist include. I thought we were in compliance with what we were doing. What is the checklist he is referring to?

“K 353: Maintenance record review revealed that the facility failed to provide record of weekly inspection of the fire pump assembly operating and physical condition. Not in accordance with NFPA 25, 2011 edition Section 8.2.1, 8.2.2.”

What does a weekly inspection of the fire pump assembly operating and physical condition entail?

“K293: Facility failed to provide record of monthly (interval not to exceed 30 days) visual inspection of the operation of illumination source of emergency exit signs installed in the facility. Not in accordance with NFPA 101 2012 edition Section”

Currently we have had the practice of conducting a monthly load bank test of the generator. During this test, checking and logging the exit lights is part of the test. Need clarification of what the visual inspection includes. Thought we were in compliance.

A: Do you have a copy of NFPA 25-2011? If not, I suggest you obtain a copy.

NFPA 25-2011, section requires the following visual observations while the pump is operating:

(1) Pump system procedure as follows:

(a) Record the system suction and discharge pressure gauge readings

(b) Check the pump packing glands for slight discharge

(c) Adjust gland nuts if necessary

(d) Check for unusual noise or vibration

(e) Check packing boxes, bearings, or pump casing for overheating

(f) Record the pump starting pressure

(2) Electrical system procedure as follows:

(a) Observe the time for motor to accelerate to full speed

(b) Record the time controller is on first step (for reduced voltage or reduced current starting)

(c) Record the time pump runs after starting (for automatic stop controllers)

(3) Diesel engine system procedure as follows:

(a) Observe the time for engine to crank

(b) Observe the time for engine to reach running speed

(c) Observe the engine oil pressure gauge, speed indicator, water, and oil temperature indicators periodically while engine is running

(d) Record any abnormalities

(e) Check the heat exchanger for cooling waterflow


NFPA 25-2011, section refers to Table for inspection frequencies. Table says the fire pump house and fire pump system must be inspected weekly. Sections 8.2.1 and 8.2.2 require the following inspections to verify that the pump assembly appears to be in operating condition and is free from physical damage:

(1) Pump house conditions as follows:

(a) Heat is adequate, not less than 40°F (5°C) for pump room with diesel pumps without engine heaters.

(b) Ventilating louvers are free to operate.

(2) Pump system conditions as follows:

(a) Pump suction and discharge and bypass valves are fully open.

(b) Piping is free of leaks.

(c) Suction line pressure gauge reading is within acceptable range.

(d) System line pressure gauge reading is within acceptable range.

(e) Suction reservoir is full.

(f) Wet pit suction screens are unobstructed and in place.

(g) Waterflow test valves are in the closed position.

(3) Electrical system conditions as follows:

(a) Controller pilot light (power on) is illuminated.

(b) Transfer switch normal pilot light is illuminated.

(c) Isolating switch is closed — standby (emergency) source.

(d) Reverse phase alarm pilot light is off, or normal phase rotation pilot light is on.

(e) Oil level in vertical motor sight glass is within acceptable range.

(f) Power to pressure maintenance (jockey) pump is provided.

(4) Diesel engine system conditions as follows:

(a) Fuel tank is at least two-thirds full.

(b) Controller selector switch is in auto position.

(c) Batteries’ (2) voltage readings are within acceptable range.

(d) Batteries’ (2) charging current readings are within acceptable range.

(e) Batteries’ (2) pilot lights are on or battery failure (2) pilot lights are off.

(f) All alarm pilot lights are off.

(g) Engine running time meter is reading.

(h) Oil level in right angle gear drive is within acceptable range.

(i) Crankcase oil level is within acceptable range.

(j) Cooling water level is within acceptable range.

(k) Electrolyte level in batteries is within acceptable range.

(l) Battery terminals are free from corrosion.

(m) Water-jacket heater is operating.


I don’t know what your current inspection logs say regarding the ‘Exit’ sign inspections, but apparently, the surveyor did not feel it met the requirement of section of the 2012 LSC. ‘Exit’ signs must be inspected monthly (at intervals not exceeding 30 days) to verify that the illumination sources are operating. This means the ‘Exit’ signs must be illuminated. Your inspection logs for this monthly requirement must specifically state your staff confirmed the ‘Exit’ sign is illuminated for each inspection. If the inspection log does not say that, then you did not perform the proper inspection.

If you are thinking the surveyor really hit you hard on the inspection and testing requirements described above, you’re right. But don’t blame the surveyor… he/she is only doing their job. CMS is systematically holding healthcare providers accountable for compliance with the 2012 Life Safety Code, and the referenced standards. CMS is insisting their state agencies who do validation and complaint surveys on their behalf, hold all healthcare providers accountable to every large and little NFPA requirement. If this results in the surveyor being ‘picky’, then so be it, according to CMS.

You can expect the accreditation organizations to follow suit. CMS is cracking down on them as well, and making the AOs enforce little-known NFPA requirements that were never enforced before.