03/17/2022

Survey Tip of the Week: Sprinklers

The life safety code tag K353 is the top cited K-tag in Ohio for FY 2022. The Ohio Department of Health (ODH) shared that the sprinkler inspection documentation has been lacking. Surveyors will review documentation to evaluate the following: 

• Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25
• Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
• Records shall indicate the procedure performed (e.g., inspection, test, or maintenance [ITM]), the organization that performed the work, the results, and the date.
  

ODH reminds facilities to inspect sprinkler heads for dust, especially those that are close to a vent. Sprinklers should be inspected and replaced when they are showing signs of: Leakage, Corrosion, Physical damage, Loss of fluid in the glass bulb heat responsive element, Loading, Painting (unless painted by the sprinkler manufacturer).

The Preventative Maintenance Manual has been updated and will be posted on the ODH nursing homes publications webpage. The updated manual now includes a list of required documents. Examples of documentation that will be requested include Quarterly ITM, Annual ITM, Dry System Trip test, leak test, Internal pipe and or tank (5yr), Monthly gauge inspection, Hydraulic name plate Fire Pump (weekly or monthly run & ITM), Fire Hydrants Backflow (and forward flow test if applicable), and any other ITM required by NFPA 25.

LeadingAge Ohio encourages facilities to put together the life safety code documentation, using the preventative maintenance manual list, similar to how a facility has put together the required survey documentation found in the entrance conference form. Facility leadership could utilize the preventative maintenance manual list to periodically audit the required life safety code required documentation.

For more information about the citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the April 13 call at 10:00AM.

As Ohio’s annual survey process continues, LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you’d like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.