Why Sprinklers Keep Leading to Survey Tags

Life Safety; Emergency Preparedness
​Since August 2013, CMS has required all regulated nursing homes to be fully sprinklered.  This has resulted in a decline in serious healthcare facility fires, along with the injuries and fatalities that can be associated with them.  However, the increase in sprinkler systems has accompanied an increase in life safety deficiencies.  CMS K-tags related to sprinkler system design, components, inspection, testing, and maintenance are consistently in the top five K-tag findings list nationally.  

There are two (2) commonly cited K-tags that address sprinkler systems.  K351 addresses sprinkler system installation and K353 addresses sprinkler system maintenance.  

Common survey findings related to sprinkler system installation (K351) include:
  • Obstructions (18" rule) – Items are not permitted to be stored within 18" of sprinkler heads.  This is a common problem in areas such as commissaries and storage rooms.  Placing items too close to a sprinkler head could impede the spray pattern from the head.  However, the requirement does not limit the ability to have shelving and storage around the perimeter of a room that extends to the ceiling assuming there are no sprinkler heads directly above the storage or shelf. 
  • Piping – Wire, conduit, cables, and similar items are not permitted to be attached to, supported from, or even laid across sprinkler piping.  This is a common issue above the ceiling. 
  • Overhangs / Awnings – Any overhang or awning considered combustible and spanning more than four (4) feet from the side of the building is required to have sprinkler protection provided to the space below.  This can include porticos, porte-cochères, and entry/exit awnings and overhangs.  There are special designs and specialty sprinklers that can be utilized to protect these unique areas.               
Common survey findings related to sprinkler inspection, testing, and maintenance (K353) include:
  • Testing, Inspection, and Maintenance – NFPA 25 outlines very prescriptive inspection, testing, and maintenance (ITM) requirements for sprinkler systems.  Survey findings often relate to incomplete documentation, missing ITM components, or lack of remediation when the vendor identifies an issue.  Make sure your vendors are using the 2011 edition of NFPA 25, providing comprehensive documentation, and clearly notifying you if there is a problem requiring attention. 
  • Sprinkler Head Testing or Replacement – NFPA 25 also dictates when sprinkler heads must either be tested or replaced.  The interval depends on the type of sprinkler head.  Standard response sprinklers require testing at the 50-year mark and then again every 10 years thereafter.  Fast response sprinklers, including quick response heads that are commonly found in healthcare facilities, require testing 25 years after installation and then again every 10 years thereafter.  Rather than send out a grouping of sprinkler heads to be tested, you can also replace them at the first or subsequent testing mark.  This will reset the clock for future testing requirements.  Your sprinkler vendor should be knowledgeable in determining the age of your sprinkler heads, when they require testing/replacement, and what labs can provide the testing service. 
  • Painted / Dirty Sprinkler Heads – Sprinklers may not operate as intended if they are dirty, grease laden, or painted.  Usually, a simple cleaning or dusting does the trick.  However, if paint or grease won't remove easily, the heads may need to be replaced. 
Sprinklers are proven to save property and lives.  Ensuring they are installed and maintained appropriately will keep you in compliance and keep your system in a state of readiness should a fire occur. 

Detailed sprinkler system requirements can be accessed via the National Fire Protection Association's (NFPA) website at www.nfp​a.org.  The AHCA/NCAL website is also a great resource for on-going life safety education, tools and resources.