University of Iowa Hospital & Clinics Dialysis

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 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 This Standard is not met as evidenced by: 45036 Based on observation and interview, the facility failed to inspect, test, and maintain the automatic sprinkler system within the facility by allowing an external load by material resting or hung from the pipe in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.7.5 and NFPA Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition. This deficient practice could affect all occupants within the facility. There are no patients that reside in the basement of this facility. The facility had a capacity of 20 and a census of 8 patients at the time of the survey. Findings include: 1. Observation on 2/18/2025 at 12:02 p.m., revealed a large silver metal hook which was connected to a water catch equipment that was being hung from the sprinkler line in the Basement within the Generator Room above the Generator. 2. Observation on 2/18/2025 at 12:05 p.m., revealed several bundles of cables/wires located in the tunnel leading to the Generator Room within the Basement and near the BH elevator which were zip-tied to and hanging from the sprinkler line. The Staff confirmed these observations at the times of discovery.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24 hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 45036 Based on record review, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including patients, staff, and visitors. The facility had a capacity of 20 and a census of 8 patients at the time of the survey. Findings include: 1. Record review on 2/18/2025 between 10:38 a.m. and 11:20 a.m., of the procedures for a sprinkler system outage in the facility’s outage policy did not list specifically what to do or any of the specific verbiage for the sprinkler outage policy. The policy was incomplete in that it did not address and was missing the following information: 1. All preplanned impairments shall be authorized by the impairment coordinator, who shall verify the following procedures have been implemented: (1) Evacuation of the building or portion of the building affected by the outage. (2) Establishment of a temporary water supply. (3) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire. 2. The fire department has been notified. 3. The insurance carrier, the alarm company, property owner or designated representative, and other Authorities having jurisdiction have been notified. 4. The supervisors in the areas to be affected have been notified. 5. A tag impairment system has been implemented. 6. All necessary tools and materials have been assembled on the impairment site. 2. The policy also did not contain the exact verbiage or address the following: System leakage, Interruption of water supply, Ruptured piping, and Equipment failure. 3. The policy also did not contain the contact phone numbers for the Iowa Department of Inspections, Appeals, & Licensing (DIAL), the facilities insurance carrier, or the local fire department. Within the fire watch policy itself in a separate section it did list several phone numbers for local fire departments, however, these were not contained within the sprinkler outage policy and there was no reference of where else to look in order to find these numbers such as an emergency phone contact list. Interview with the Staff revealed there were some other sections within their policies which referenced water supply, evacuation, etc. however, within the sprinkler outage policy itself there was no reference of where to look for these and they should be added specifically to the sprinkler outage policy or at least direct where to look. The Staff verified the documentation at the time of the survey and exit interview.”