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
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Observations: Name: A0101 - Component: 01 - Tag: 0353
Based on document review and interview, it was determined the facility failed to maintain required testing for the main sprinkler system fire pump, affecting the entire facility.
Findings include:
1. Documentation reviewed on March 27, 2023, between 9:30 a.m. and 10:35 a.m., revealed fire pump inspections for the main sprinkler system were not conducted on a consistent basis prior to April 2022, and after July 2022. Monthly 10 minutes runs are required for electric-driven motors.
Exit Interview with the Facility Administrator on March 27, 2023, at 11:30 a.m., confirmed fire pump testing was incomplete.
| | Plan of Correction - To be completed: 06/01/2023
1. The deficiency will be corrected as it relates to the individual by requesting proper documentation of the monthly 10 minute exercise of the fire pump. Building owner/management has been made aware of this numerous times.
2. To ensure that the problem does not occur, the administrator will visualize the log in the basement on a monthly basis with a focus on completion of the monthly 10 minute exercise of the fire pump. Missing monthly tests will be documented internally and communicated to the building owner/management immediately until corrected.
3. To ensure that this solution is sustained, the administrator will document findings in an internal log along with accompanying written communication to/from building owner/management.
4. This corrective action will be completed by 06/01/2023
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