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: PENN PRESBYTERIAN SURGERY CENTER - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance affecting one of thirteen floors.
Findings include:
Observation on May 2, 2023, at 9:40 a.m., revealed duct work resting on the sprinkler line in the pre-op equipment room.
Interview with Maintenance Staff on May 2, 2024, at 10:30 a.m., confirmed the duct work resting on the sprinkler line.
| | Plan of Correction - To be completed: 05/17/2024
Plan of Correction: 0211 Deficiency Correction of Deficiency
A contractor overseen by Facilities Management cleared the sprinkler pipe of any insultation or debris. The Facility Director verified the corrections and confirmed compliance on May15, 2024.
Actions to prevent re-occurrence:
1. The Facilities Management team notified the 3737 Building Manager and the Director overseeing the building that they must adhere to the Above Ceiling permit process when doing any work above the ceilings at 3737 Market Street. Facilities will issue a permit for above ceiling work and oversee its completion to ensure it meets standards.
2. There will be above-ceiling preventive maintenance (PM) conducted by Facility Management staff. The in-house mechanic will inspect for compliance in random locations at least monthly.
3. The Facilities Management Director or designated Plant Operations Manager will verify compliance of the monthly PMs.
Performance Improvement and Reporting
- Monthly data from the inspection will be aggregated and submitted to the quarterly Patient Safety and Quality Committees for The Surgery Center at Penn Medicine University City (PMUC) as part of the ongoing Quality Assurance and Performance Improvement program at the ASF.
- Ongoing reports will be submitted quarterly as part of the Maintenance report until compliance is sustained for at least two quarters.
Responsible Party:
The Department of Engineering, overseen by the Director of
Facilities Management is responsible for verifying that there are no wires or cables lying on the sprinkler pipes.
The Administrator, Surgery Center at Penn Medicine University City is ultimately responsible for this action plan and reporting compliance to the appropriate Surgery Center Patient Safety and Quality Committe Committees and documented.
Completion Date: May 17, 2024
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