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: ADVANCED CENTER FOR SURGERY LLC - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in three instances, affecting one of two smoke compartments.
Findings include:
1. Observation on April 25, 2024, revealed the following automatic sprinkler system deficiencies:
a) 10:10 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the receiving area;
b) 10:12 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the material management office;
c) 10:30 a.m., there were multiple unsealed penetrations in the ceiling of the sterilizer access room.
Interview with the Facility Administrator and the Maintenance Director on April 25, 2024, at 11:30 a.m., confirmed the listed automatic sprinkler system deficiencies.
| | Plan of Correction - To be completed: 05/09/2024
A.
1. To correct the 18-inch horizontal sprinkler deficiency in the receiving area, we have removed all objects from the top shelves. The items were placed in a designated storage area. This occurred on 04/26/2024.
2. To ensure the facility maintains compliance, our maintenance/assistant clinical director will observe the items in the storage area on a weekly basis.
3. The appropriate clinical staff were educated on proper storage of items to ensure safety and compliance.
B.
1. To correct the 18-inch horizontal sprinkler deficiency in the materials managers office area, we have removed all objects from the top shelves. The items were placed in a designated storage area. This occurred on 04/26/2024.
2. To ensure the facility maintains compliance, our maintenance/assistant clinical director will observe the items in the materials managers office on a weekly basis.
3. The appropriate clinical staff were educated on proper storage of items to ensure safety and compliance.
C.
1. The maintenance/assistant clinical director has scheduled R.T. Contracting to seal the unsealed penetrations around the piping in the sterilizer access room. This work will be completed by 05/08/2024.
2. To ensure the surgery center is in compliance with Life Safety Code requirements for an existing Ambulatory health care facility, the maintenance/assistant clinical director will thoroughly examine the building on a weekly basis. Any items that fail to meet code, will be addressed and corrected within 30 days of findings.
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