Missing Documentation for Sprinkler System Maintenance and Testing
Penalty
Summary
The facility failed to provide required documentation for the inspection, testing, and maintenance of its automatic sprinkler systems as mandated by NFPA 25. During a document review, it was found that records were missing for several critical maintenance activities, including semi-annual valve supervisory switches and pressure switch waterflow alarm checks, 1st and 3rd quarterly inspections, annual main drain/control valve tests, annual dry system partial trip tests, and the 3-year dry system full trip test. These deficiencies were confirmed during interviews with the Director of Nursing and Director of Maintenance, who acknowledged the absence of the necessary documentation for the facility's installed sprinkler systems. Additionally, a review of records and interviews revealed that the previous sprinkler company, Johnson Controls, had reported a 3-year air leak failure during an inspection, but the facility could not provide documentation confirming that the 3-year leak test was performed or that the identified deficiency in the dry sprinkler system was repaired. The lack of documentation for these required maintenance and testing activities affected the entire sprinkler system component.
Plan Of Correction
1 The facility is unable to retroactively perform this testing. 2 Testing will be completed for the wet/dry valve system. Three-year leak tests will be performed. The facility will ensure that all verifying documentation is received and on the premises of any inspections that are completed. 3 The Environmental Services Director was re-educated on the requirements of K0353. 4 The NHA or designee will complete an annual audit of the tests of the wet/dry valve system in August x 2 years. The results will be submitted to the QAPI Committee for review and analysis of the need for ongoing monitoring.