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: CLASS C ASF - Component: 01 - Tag: 0353
Based on observation, document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting two of three levels.
Findings include:
1. Document review on May 17, 2023, at 9:55 am, revealed the facility could not produce documentation showing quarterly sprinkler inspections had been performed for the 3rd quarter of 2022.
Exit Interview with the Administrator and Project Supervisor on May 17, 2023, at 11:10 am, confirmed the missing documentation.
2. Observation on May 17, 2023, at 10:15 am, revealed in OR-1 closet, items were stored directly under and within 18 inches of the sprinkler.
Exit Interview with the Administrator and Project Supervisor on May 17, 2023, at 11:10 am, confirmed the obstructed sprinkler.
| | Plan of Correction - To be completed: 05/18/2023
1. As part of our Plan of Correction our Facility has a contract with Common Wealth Fire Protection to perform our quarterly sprinkler inspections. They were unable to satisfy their requirements of the contract for one quarter in 2022. Common Wealth Fire Protection had preemptively performed the third quarter of 2022 inspection still within the second quarter which led to the deficient gap that was found in services. They have since performed inspections for the fourth quarter December 2022, and first quarter March 2023. Moving forward, Common Wealth Fire Protection is to be called for appointments each quarter by the building manager and or Administrator to confirm for quarterly inspection by Common Wealth Fire Protection to perform the quarterly sprinkler inspections within the required time period, sign off on the paperwork after the inspection is performed, and report the findings to the Governing Body each quarter.
2.As part of our Plan of Correction at our Facility the items that were observed during the inspection within 18 inches of the sprinkler were immediately removed and reallocated. To ensure the deficiency will not occur a sign was placed to remind staff to not store items within 18" of the closet sprinkler. The staff was in serviced on the directive an 18 inch clearance from sprinkler heads be maintained and to notify the building manager or administrator if deficiencies were found to be corrected. An audit will be conducted the storage closet in OR 1 weekly 4 times then monthly 3 times by the building manager to ensure ongoing compliance. The results of the audit observations will be reported, reviewed and trended results will be reported to the Governing Body for further recommendations.
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