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 document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.
Findings include:
1. Document review on February 20, 2024, at 9:00 am, revealed the September 7, 2023, annual sprinkler inspection report listed the following deficiencies, evidence of corrective action was not available at time of survey:
a. 5-year hydro due. b. No hydraulic nameplate c. ITC Kitchen did not terminate in smooth orifice. d. ITC Basement housekeeping did not terminate in smooth orifice. e. 1-1/4 test drain not connected to main drain.
Exit interview with the Administrator and Maintenance Director on February 20, 2024, at 12:00 pm, confirmed the sprinkler system deficiencies.
2. Document review on February 20, 2024, at 9:00 am, revealed the December 5, 2023, quarterly sprinkler inspection report listed the following deficiency, evidence of corrective action was not available at time of survey:
a. Test & drain valve is plugged off at the sectional and is not piped out, so flow switch is unable to be tested with flowing water.
Exit interview with the Administrator and Maintenance Director on February 20, 2024, at 12:00 pm, confirmed the sprinkler system deficiency.
| | Plan of Correction - To be completed: 04/20/2024
The facilities service vendor has been contacted to obtain the necessary documentation to clear deficiencies that have already been completed.
And quotes for the modifications and repairs needed to clear the Hydro test and test drain plug deficiencies are being obtained.
The hydraulic name plate information has been supplied to an outside vendor and will be replaced by that outside contractor.
Moving forward documentation review will be completed semiannually to ensure corrective action information is available at time of inspection.
The results of all audits will be reviewed at the Quality Assurance & Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/ interventions for ongoing compliance.
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