Documentation- Part 3: Sprinkler System

imagesJ0Z09XQXThis is the third in a series of articles on improving the way the testing & inspection documents are maintained, in order to facilitate an easier document review session during a survey.

Last week I talked about the fire alarm system testing documentation. There are potentially over 25 different devices that a typical hospital fire alarm system may have, and some hospitals tend to over-look the occupant notification devices and the interface relays. Make sure your reports include these devices.

Sprinkler systems have many different components, most of which are hidden from view to the general public. If you haven’t already, take the time to investigate whether or not you have these devices in your facility. It is unlikely that any hospital would have every device listed below, but all of these devices have been observed in one healthcare institution or another.

Device/Test/Inspection

Frequency

NFPA   Standard

Fire pump churn test

Weekly

25-1998; 5-3.2.1

Control valve inspection

Monthly

25-1998; 9-3.3.1

Fire department connections

Quarterly

25-1998; 9-7.1

Pre-action/Dry pipe valve priming   water test

Quarterly

25-1998; 9-4.4.2.1

Sprinkler inspection

Annually

25-1998; 2-2.1.1

Piping & hanger inspection

Annually

25-1998; 2-2.2

Pre-action/Dry pipe valve trip test

Annually

25-1998; 9-4.4.2.2

Main drain test

Annually

25-1998; 9-2.6

Control valve exercise

Annually

25-1998; 9-3.4.1

Backflow preventer

Annually

25-1998; 9-6.2

Anti-freeze test

Annually

25-1998; 2-3.4

Private service fire hydrants

Annually

25-1998; 4-3.2

Fire pump flow test

Annually

25-1998; 5-3.3.1

Occupant use fire hose – inspection

Annually

1962-1998; 2-3.3

Occupant use fire hose – pressure   test

5-Years after installation; then   every 3-Years

1962-1998; 2-3.2

Check valve inspection

5-Years

25-1998; 9-4.2.1

Pressure gauge calibration

5-Years

25-1998; 2-3.2

Standpipe waterflow test

5-Years

25-1998; 3-3.1

Private fire service mains

5-Years

25-1998; 4-3.1

Internal inspection of system piping   (if obstruction conditions)

5-Years

25-1998; 10-2.2

QR sprinkler head replacement

20-Years

25-1998; 2-3.1.1

SR sprinkler head replacement

50-Years

25-1998; 2-3.1.1

If you contract your sprinkler system testing and inspection activities, take this list and sit down with your contractor and review with them if they are performing these functions. The above list does not take into consideration any alternative frequencies based on the CMS categorical waivers.

If you want to download a copy of the complete list of requirements for the document review session, go to “Tools” page, and click on “Acute Care Hospital Documentation Requirements”. You will find the file under the Life Safety Document Review heading.

Next week we will look at the final installment and rest of the list of items needed for the document review session.