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 - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system to be free from extraneous weight, affecting the entire component.
Findings include:
1. Observation on January 8, 2025, at 11:16 AM, revealed the support for the vacuum pump exhaust pipe, located within the Mechanical Room, was supported by and bracketed to sprinkler piping within the room.
Interview with the Clinical Director on January 8, 2025, at 11:16 AM, confirmed the vacuum exhaust pipe was supported by the sprinkler system.
| | Plan of Correction - To be completed: 02/28/2025
The Vacuum Pump vendor will be contacted, and a service call will be set up to evaluate the issue and determine if the support bracket is redundant and if so removed or if needed, a new support bracket will be installed that separates any pipe contact between the vacuum and sprinkler systems.
The Administrator/CEO will confirm that the repairs have been made and that the problem has been resolved.
Ongoing monitoring is not needed once the problem has been resolved, however while the vacuum pump vendor is onsite, they will be asked to review all piping and pipe support systems to ensure that no other issues are present. If they are, they will also be corrected at that time.
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