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: MAIN BUILDING - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler piping system to be free of extraneous weight, affecting two of nine smoke compartments within the component.
Findings include:
1. Observation on January 29, 2024, between 11:30 AM and 11:45 AM, revealed items were being supported by the sprinkler piping system, at the following locations:
a. 11:30 AM, Main Corridor, above ceiling, by Service Hall, various wires, insulated pipes and pull lines; b. 11:40 AM, Main Corridor, above ceiling, by Therapy, flex conduit and wires; c. 11:45 AM, F Hall, above ceiling, by smoke doors, various rigid pipes and wires.
Interview at the time of the exit conference with the Administrator and Director of Environmental Services on January 29, 2024, at 1:45 PM, confirmed various items laying across sprinkler pipes.
| | Plan of Correction - To be completed: 03/29/2024
The facility is bringing in its contracted construction partner to perform a survey and remediation of items laying on or touching/adding weight to the sprinkler system lines. Removal of said wires and items will be performed in the areas of the main corridor and the F hallway. This procedure will also be incorporated for the building as part of the HVAC renovation already in progress.
The facilities maintenance program will conduct quarterly inspections/audits throughout the building. Inspections and audits discrepancies will be reported to the QAPI committee for review and recommendation.
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