On August 13, 2008 the Center for Medicare & Medicaid Services (CMS) published its final Regulation mandating sprinklers in all existing nursing homes regardless of the construction type of the building. The new Regulation is effective October 14, 2008 and all nursing homes must be fully sprinklered by August 13, 2013. This will allow all existing nursing homes that are not fully sprinklered up to 5 years to install the new sprinklers. There are no provisions in the regulation to extend the time frame for compliance beyond August 13, 2013. All new nursing homes are currently required to be fully sprinklered.
The Regulation will not allow any exceptions. That is, no nursing home will be allowed to avoid installing sprinklers based on the use of the Fire Safety Evaluation System (FSES) or by waiver. The Regulation states that the sprinkler systems have to be installed in accordance with the 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems. The 1999 NFPA 13 is the appropriate reference standard for the 2000 Life Safety Code. Although not specifically addressed in the Regulation, if your state requires compliance with a more recent edition of NFPA 13, most likely this will be acceptable to CMS. Compliance with a more recent edition of NFPA 13 should be confirmed in writing from both the state and your CMS Regional Office.
CMS has also informed AHCA that existing waivers for sprinkler deficiencies or the use of the Fire Safety Evaluation System for sprinkler deficiencies will not be extended. Existing facilities that have sprinkler deficiencies and are operating under a waiver or FSES have until August 13, 2013 to correct the deficiencies.
If your building is partially sprinklered, for example an addition is sprinklered but the original building is not sprinklered, the sprinkler system in the addition does not have to be changed to comply with the 1999 NFPA when the original building is sprinklered. If you are told that when you install your new sprinkler system that your existing sprinkler system has to be upgraded requiring extensive and expenses changes, you should ascertain why and you might want to consider seeking an opinion from a qualified fire protection engineer.
On March 25, 2005 CMS published an interim final rule ( final rule was published on September 22, 2006) that mandated, as a minimum, that battery operated smoke detectors be installed in all resident sleeping rooms and public areas of all nonsprinklered nursing homes. Please note that the rule only applies to nonsprinklered buildings. Therefore, once you sprinkler your building, the CMS rule will no longer apply to your newly sprinklered building. The CMS smoke detector rule was only intended to be an interim action until CMS issued a mandatory sprinkler requirement which they have now done.
If your state does not have a mandatory smoke detector requirement for resident rooms and public areas, you can remove the smoke detectors once the sprinklers are installed, tested and approved. One exception is for buildings that are classified as a new building under the 2000 Life Safety Code. New buildings are required to install smoke detectors in corridors in smoke compartments that contain resident sleeping rooms. Do not accept the argument from your fire authority that the Life Safety Code does not allow reducing the level of fire safety, i.e. removing the smoke detectors, in an existing building. What the Life Safety Code states is that the level of fire safety in an existing building cannot be reduced below that which is required for new buildings. Smoke detectors are not required in resident sleeping rooms or public areas in the Life Safety Code for new buildings, therefore the smoke detectors in your existing building can be removed. If you decide NOT to remove the smoke detectors then the smoke detectors must be tested and maintained in accordance with NFPA 72, National Fire Alarm Code. Battery operated smoke detectors are not recommended for permanent installations of smoke detectors in nursing homes and should be removed once the new sprinkler systems are installed.
CMS issued a Survey and Certification Letter (S & C-09-04) on October 3, 2008 that provides more details on the new Mandatory Sprinkler System Regulation for Nursing Homes. You can obtain a copy of Letter S & C-09-04 from the following CMS web site http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp#TopOfPage or from the AHCA Members Only Web site.
This Update has been reviewed by CMS.