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: ENDO CENTER - Component: 01 - Tag: 0353
Based on document review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the entire facility.
Findings include:
1. Review of documentation on June 10, 2024, at 8:50 a.m., revealed the facility lacked documentation for a sprinkler pipe obstruction inspection performed within the last five years.
Interview with the Maintenance Staff on June 10, 2024, at 8:50 a.m., confirmed the facility lacked five-year obstruction inspection documentation at the time of the survey.
| | Plan of Correction - To be completed: 06/27/2024
1. 5 Year Fire Sprinkler Hydrostatic Test recently performed on 9335 MCKNIGHT ROAD, SUITE 200, PITTSBURGH, PA, 15237 5949, US:
INSPECTOR DETAILS
Inspector: Lawrence Thomas
Inspector Email: lawrence.thomas@jci.com
CUSTOMER DETAILS
Customer: McCandless Endoscopy Center
Building: McCandless Endoscopy Center - Sprinkler
Building Address: 9335 MCKNIGHT ROAD, SUITE 200, PITTSBURGH, PA, 15237 5949, US
INSPECTION DETAILS
Date: 06/20/2024
Inspection Type: 5 Year Fire Sprinkler Hydrostatic Test
Frequency or EP: 5 Year
Work Order Number: 57194470
(Copy of the completed report is located at McCandless Endoscopy Center)
2. Completed on 6/20/2024. Next inspection is due 06/2029
3. AHN Maintenance has been made aware that the 5-year fire sprinkler hydrostatic test needs to be completed every 5 years and also has been shown where the expectation is located on the DOH Life Safety checklist. The administrator of McCandless Endoscopy Center is adding a quarterly review with AHN Maintenance to review the Life Safety checklist for completion and compliance.
4. The quarterly review between the administration and AHN Maintenance to review List Safety checklist will then be reported out during the Quality Assessment and Performance Improvement (CQI) meeting and added to the meeting minutes that are placed into the Department of Health binder in the management office. This report will include inspections completed during the quarter and upcoming requirements. The requirement for sprinkler pipe obstruction inspection will be documented in the CQI meeting minutes.
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