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 - Component: 01 - Tag: 0353
Based on document review, observation and interview, it was determined the facility failed to maintain the sprinkler piping system, to be free of extraneous weight, failed to provide 5-year maintenance and testing documentation, and failed to maintain the automatic sprinkler system free from obstruction, affecting the entire component.
Findings include:
1. Observation on June 6, 2022, between 12:10 PM and 12:20 PM, revealed items were being supported by the sprinkler piping system, at the following locations:
a. 12:10 PM, above smoke door, to South Wing by Restroom, coat hanger wire wrapped around sprinkler; b. 12:20 PM, above ceiling, Nurses' Station by Soiled Linen Closet, various cable wires tied to sprinkler piping system.
Interview at the time of the exit conference with the Maintenance Director and Administrator on June 6, 2022, at 2:15 PM, confirmed there were various items attached to the sprinkler pipes.
2. Observation on June 6, 2022, at 12:30 PM, revealed one sprinkler head covered with dust, directly above the dryers, in the Laundry Room duct chase closet.
Interview at the time of the exit conference with the Maintenance Director and Administrator on June 6, 2022, at 2:15 PM, confirmed the obstructed sprinkler head.
3. Review of Documentation and observation on May 9, 2022, between 8:45 AM and 11:30 AM, it was revealed the facility was unable to verify when the sprinkler system internal pipe and internal valve inspections had been performed, within the past five years.
Interview at the time of the exit conference with the Maintenance Director and Administrator on June 6, 2022, at 2:15 PM, confirmed the lack of documentation.
| | Plan of Correction - To be completed: 07/11/2022
All items will be removed from sprinkler piping system. Quarterly audits will be done by the Maintenance Department for the sprinkler piping system to ensure items are not being supported by the sprinkler piping system.
Quarterly audits will be done by Maintenance Department of all sprinkler heads to ensure that they are free from debris and dust.
Susquehanna Sprinkler Company was called and appointment made for inspection of sprinkler system internal pipe and internal valve will be performed. This inspection will be added to our annual inspection list by the Maintenance Department to ensure that it is scheduled annually going forward.
Results of audit will be reported quarterly to the Quality Assurance Committee for review.
|
|