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
|
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353
Based on document review, observation and interview, it was determined the facility failed to provide quarterly inspection documentation and sprinkler piping system, to be free of extraneous weight, affecting the entire component.
Findings include:
1. Review of documentation on October 25, 2023, between 9:00 AM and 10:30 AM, revealed the facility lacked documentation for the 2nd quarter of 2023 inspection, of the dry sprinkler system.
Interview at the time of the exit conference with the Regulatory Compliance Coordinator, Accreditation & Licensure Manager, Emergency Management Manager, Senior Properties Coordinator and Facilities Technician on October 25, 2023, at 1:30 PM, confirmed the facility could not provide all quarterly inspection reports.
2. Observation on October 25, 2023, between 11:40 AM and 11:50 AM, revealed various items laying across the sprinkler piping system, at the following locations:
a. 11:40 AM, above ceiling, corridor, by the Conference Room, various tele-communication wires;
b. 11:50 AM, above ceiling, above smoke doors, in the corridor by the Housekeeping Closet, various tele-communication wires and rigid pipes.
Interview at the time of the exit conference with the Regulatory Compliance Coordinator, Accreditation & Licensure Manager, Emergency Management Manager, Senior Properties Coordinator and Facilities Technician on October 25, 2023, at 1:30 PM, confirmed the sprinkler piping system was subject to extraneous weight.
| | Plan of Correction - To be completed: 11/03/2023
Plan of Correction:
1. Work order # 202329818was entered on October 23, 2023, for quarterly inspection of the dry sprinkler system to be completed by Commonwealth Fire Protection (CFP) to ensure quarterly inspections are completed.
2. Work order # 2023313083 was entered on November 2, 2023, to evaluate all current above ceiling areas to ensure compliance with no wires laying on the sprinkler piping system.
Systemic Changes Implemented to Prevent Recurrence of the Deficiencies:
1. Quarterly report from Commonwealth Fire Protection (CFP) will be sent by senior property coordinator to manager of Accreditation and Licensure for validation that inspection was completed.
2. The above ceiling access permit process will be instated. Any vendor or WellSpan department doing work above the ceiling will have the planned above ceiling work reviewed and issued a permit. When the work is completed, engineering will complete a visual inspection of the above ceiling work to ensure compliance. Monthly report of permit process sent to manager of Accreditation and Licensure.
Person Responsible for Corrective Actions:
Senior Properties Coordinator
Method for Monitoring:
PM tasks as described above.
Frequency of Monitoring: 1. Quarterly 2. Monthly
Measure of Effectiveness:
100% of PM activities will demonstrate compliance with NFPA Standards.
Corrective actions will be determined effective after three consecutive months of 100% compliance. After sustained compliance is achieved, monitoring will transition to checks completed during Environment of Care Rounds. Monitoring results will be provided by the Sr. Properties Coordinator and reported monthly to the Surgery Center's Quality Management
|
|
