|Sprinkler System - Maintenance and Testing|
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Name: MAIN BUILDING - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to inspect the automatic sprinkler system, on one of one system within the component.
1. Observation on May 22, 2019, between 10:50 AM and 11:10 AM revealed sprinkler valves lacked metal UL-approved signs attached with wire or chains to the valve assemblies, in the following locations:
a. 10:50 AM, West Wing 200 Hall, Biohazard Room;
b. 10:55 AM, Main Patio;
c. 11:10 AM, East Wing, Biohazard Room.
Interview with the Maintenance Director on May 22, 2019, at 11:10 AM confirmed the automatic sprinkler valves lacked UL-approved signs.
| ||Plan of Correction - To be completed: 07/08/2019|
West wing 200 hall biohazard room, main patio and east wing biohazard room will have UL-approved signs attached with wire or chains to the fixture.
All sprinkler valves will have UL-approved signs attached with wire or chains to the fixture.
Maintenance staff will be re-educated on using UL-approved signs attached with wire or chains to the fixture.
The maintenance staff/designee will audit 2 areas weekly for 4 weeks to ensure that UL-approved signs are attached with wire or chains to the fixture. Audits will be reviewed monthly at QAPI.