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 protection system to be free from extraneous weight, affecting one of two smoke compartments within the component.
Findings include:
1. Observation on February 25, 2025 between 10:10 AM and 10:15 AM, revealed the following items were supported by the sprinkler system, within the Mechanical/Medical Vacuum Room:
a) 10:10 AM, white wire, zip-tied in three locations;
b) 10:15 AM, water heater exhaust, wire-tied in one location.
Interview with the Senior Property Coordinator on February 25, 2025, at 10:15 AM, confirmed the wire and exhaust were suspended from the sprinkler system.
| | Plan of Correction - To be completed: 02/27/2025
Plan of Correction:
Work order #2025426363 was entered on February 25, 2025, to remove all items on the sprinkler lines in the mechanical room. Work order # 2025426886 was entered on February 27, 2025, to evaluate all current above ceiling areas with sprinkler lines to ensure compliance with no items being supported from the sprinkler lines. The facility will maintain the compliance of nothing supported by sprinkler lines.
Systemic Changes Implemented to Prevent Recurrence of the Deficiencies:
An above ceiling access permit process will be instated. Any vendor or WellSpan department doing work above the ceiling will have the planned above ceiling work reviewed and issued a permit. When the work is completed, engineering will complete a visual inspection of the above ceiling work to ensure compliance. Monthly report of permit process sent to supervisor of Accreditation and Licensure.
Person Responsible for Corrective Actions:
Manager – Engineering
Method for Monitoring:
Preventative maintenance tasks as described above.
Frequency of Monitoring:
Monthly
Measure of Effectiveness:
100% of preventative maintenance activities will demonstrate compliance with NFPA Standards.
Corrective actions will be determined effective after three consecutive months of 100% compliance. After sustained compliance is achieved, monitoring will transition to checks completed during Environment of Care Rounds. Monitoring results will be reported monthly to the Surgery Center's Quality Management Council (QMC) by the Manager – Accreditation and Licensure.
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