AEM Program for Fire Alarm and Sprinklers

Q: Are sprinklers, smoke detectors, etc. considered to be operating components of the utility systems? If so, our inspections are based on the pertinent NFPA references. I think that the fire system inspections could be considered preventive maintenance or at least the means to determine what maintenance needs to be completed. Can we use the CMS AEM program to alter our PM activities on the fire alarm and sprinkler systems?

A: You cannot use the CMS AEM program for Fire Alarm inspection and testing requirements. The CMS S&C letter 14-07 that describes the AEM program says the following regarding when the AEM program is not appropriate: “Other CoPs require adherence to manufacturer’s recommendations and/or set specific standards. For example: The National Fire Protection Association Life Safety Code (LSC) requirements incorporated by reference at 42 CFR 482.41(b) has some provisions that are pertinent to equipment maintenance, and compliance with these requirements are assessed on Federal surveys.”

So… you must follow the NFPA requirements specified for sprinkler and fire alarm testing and inspection, and the AEM program is not applicable.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.