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
|
Observations:
Name: MAIN LINE VASCULAR INSTITUTE - Component: 01 - Tag: 0353
Based on document review and interview, it was determined the facility failed to maintain, inspect, and test fire sprinkler systems, in one of four annual quarters.
Findings include:
1. Document review on July 19, 2022, at 10:37 a.m., revealed the facility lacked documentation to indicate a quarterly test of the fire sprinkler system was performed during the first quarter.
Exit Interview with the Director of Nursing on July 19, 2022, at 11:45 a.m., confirmed the above fire sprinkler inspection was not on-site during the time of the survey.
| | Plan of Correction - To be completed: 08/31/2022
The Director of Nursing will be responsible for ensuring that the Sprinkler System is inspected quarterly as per State regulations. This will be audited Quarterly and documented on the Monthly Environment of Care checklist. Audits will be reported to the Quality Assurance Committee, which reports to the Governing Body. Any deficiencies will be addressed by the governing body. All staff will be in-serviced on the required Sprinkler inspections, by 8/31/2022. In-service records will be reported to the Patient Safety Committee which reports to the Quality Assurance Committee. Any Deficiencies will be addressed by the Governing Body.
|
|
