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: GASTROINTESTINAL ENDOSCOPY CENTER LLC - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain and test the automatic sprinkler system, affecting the entire facility.
Findings include:
Document review on June 27, 2024, between 8:30 a.m. and 9:30 a.m., revealed the facility could not provide documentation of the 2024, First-Quarter sprinkler inspection.
Exit interview with the Administrator on June 27, 2024, at 10:45 a.m., confirmed the missing documentation.
| | Plan of Correction - To be completed: 07/08/2024
The contracted Sprinkler Company was contacted in March 2024 by the Administrator for a report of the 1st QTR 2024 sprinkler inspection. They stated they had not done the inspection as they had a change in staff and the person responsible for scheduling the sprinkler inspections was no longer with the company. An inspection was requested ASAP and was performed on April 11, 2024, which was the 2nd QTR.
The Sprinkler Company was contacted following the building inspection on June 27, 2024. Sprinkler inspections will be conducted the 3rd week of the 1st month of each quarter. The next sprinkler inspection will be conducted on Tuesday July 16th, 2024, and then on October 14, 2024. Reports are to be emailed to the Administrator as soon as completed by the technicians. The Sprinkler Company will notify the Administrator of any changes in personnel or problems related to performing the inspection as scheduled.
Completion of the quarterly sprinkler testing will be included in the Environment of Care monitoring performed by the DON and reported to the Patient Safety Committee on 7/22/2024and the BOM on 7/25/2024. Thereafter it will be reported quarterly.
The BOM, through the Administrator and DON, will ensure that this POC is effective, and compliance is maintained.
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