Sprinkler Inventory

Q: We are a life safety service company that provides consultation services for multiple hospitals. We had a hospital go through a survey recently, and the surveyor wrote them up for not having an inventory of sprinkler heads. Would you know where we could find this requirement for this inventory?

A: The surveyor may be looking at NFPA 13-2010, section, which does require the facility to have a spare sprinkler list, which is based on the different types of sprinklers in your facility and the quantity of those sprinklers. While this is not the same as saying an inventory of the sprinkler heads is required, you do need to know the types and quantities of sprinklers in your facility.

Or the surveyor may be looking at NFPA 25-2011 section 5.2.1, which requires an annual inspection of all the sprinkler heads. Usually, the hospital will contract this out to a sprinkler contractor and often the report simply says “All sprinkler heads inspected”, or something like that. The problem is, how does the hospital know that the contractor actually inspected every sprinkler head in the hospital? Did the contractor enter every room, every closet, every office, every OR, every equipment room, etc. in the facility? Without a detailed inventory or documentation (such as drawings of sprinklered areas) showing the heads were inspected in the respective areas, what assurance does the hospital (and the surveyor) have that every head was inspected?

But to be sure, there is no direct NFPA standard that says “Thou shalt inventory every sprinkler”, but it is well within the right of the authorities to request documentation that assures how the facility documented the spare sprinkler list and that the contractor inspected every head.

Sprinkler Inventory List

Q: NFPA 13, 2010 edition, sections & Do I read this to mean every sprinkler in every room and hallway in a hospital should be on an itemized list?

A: Well… yes and no. If you are asking if every sprinkler in the facility needs to be on an inventory list that identifies the precise location of each sprinkler installed, then no, that is not the intent of NFPA 13-2010, section (although, that’s a good inventory list to have).

But section does require a list of sprinklers used (but not where they are installed) in the facility, that includes:

  • The sprinkler model number or identification number from the manufacturer;
  • A general description, such as upright or pendant; temperature rating; concealed; extended coverage; Quick-response; etc.
  • The quantity of each type to be sprinkler to be maintained as spares in the Spare Sprinkler Cabinet;
  • Issue or revision date of the list.

This information can be obtained from the “Contractor’s Material and Test Certificate” that was required to be submitted to the owner after the installation of the sprinkler system.

NFPA 13-2010, section 6.2.9 requires spare sprinklers to be maintained so there can be a quick replacement of any sprinkler that has operated or became damaged. You are required to maintain at least two spare sprinklers for each type of sprinkler installed in your facility, but never less than a combined total of six spare heads.

  • For a facility that has fewer than 300 total sprinklers, you are required to maintain a combined total of six spare sprinklers.
  • For a facility that has 300 to 1,000 total sprinklers, you are required to maintain a combined total of 12 spare sprinklers.
  • For a facility that has more than 1,000 sprinklers, you are required to maintain a combined total of 24 spare sprinklers.

So, for some hospitals that have more than 1,000 sprinklers, but only 4 different types of sprinklers are installed in the hospital, that would require them to maintain 6 spare sprinklers of each type. But understand, if the hospital has only two specialty sprinklers installed in the hospital (such as high temperature heads in the boiler room), then there is no requirement to stock 6 spare heads of that type. You may stock just the two heads. A wrench for installing each type of sprinkler is required, which mean if four different wrenches are required to install the four different styles of sprinklers, then that is what you need to maintain. Where dry sprinklers of different lengths are installed in the facility, then spare dry sprinklers are not required.

Fire Extinguisher Documentation

fire-extinguisher-sm[1]A surveyor recently cited an organization stating the hospital did not have a document indicating all of the portable fire extinguishers were inspected on a monthly basis. The surveyor asked for a document whereby the organization knows where each portable fire extinguisher is located, and assurance that each extinguisher received its monthly inspection. The hospital did not have such a document and the surveyor cited them for non-compliance with the standard that addresses portable fire extinguishers.

A subsequent conversation with the facility manager of the organization revealed that every portable fire extinguisher that the surveyor inspected did in fact have an annual maintenance tag with the monthly inspections properly identified on each extinguisher. Apparently, the surveyor thought the hospital should have a master list indicating the locations of each portable fire extinguisher, along with documentation that they were inspected monthly. This master list indicating the locations of all the fire extinguishers is a fine idea, but it is not a requirement for compliance with any NFPA code or standard, nor any accreditation organization’s standard. This is what is called “Best Practice” and is not required to be enforced upon the healthcare organizations. Best Practice may be shared with the organization by the surveyor as a suggestion on how they may make improvements, but it is not a requirement. Be assured that NFPA codes and standards do require documentation of the monthly inspections of the fire extinguishers, but they do not stipulate how that inspection is to be documented. Some hospitals like to use the bar-code method to document the inspection, but the most common approach to document this monthly inspection is to mark the date (month and day) along with the initials of the inspector on the annual maintenance tag attached to the extinguisher.

This finding was removed from the survey report during the clarification process.

Documentation- Part 3: Sprinkler System

imagesJ0Z09XQXThis is the third in a series of articles on improving the way the testing & inspection documents are maintained, in order to facilitate an easier document review session during a survey.

Last week I talked about the fire alarm system testing documentation. There are potentially over 25 different devices that a typical hospital fire alarm system may have, and some hospitals tend to over-look the occupant notification devices and the interface relays. Make sure your reports include these devices.

Sprinkler systems have many different components, most of which are hidden from view to the general public. If you haven’t already, take the time to investigate whether or not you have these devices in your facility. It is unlikely that any hospital would have every device listed below, but all of these devices have been observed in one healthcare institution or another.



NFPA   Standard

Fire pump churn test


25-1998; 5-3.2.1

Control valve inspection


25-1998; 9-3.3.1

Fire department connections


25-1998; 9-7.1

Pre-action/Dry pipe valve priming   water test


25-1998; 9-

Sprinkler inspection


25-1998; 2-2.1.1

Piping & hanger inspection


25-1998; 2-2.2

Pre-action/Dry pipe valve trip test


25-1998; 9-

Main drain test


25-1998; 9-2.6

Control valve exercise


25-1998; 9-3.4.1

Backflow preventer


25-1998; 9-6.2

Anti-freeze test


25-1998; 2-3.4

Private service fire hydrants


25-1998; 4-3.2

Fire pump flow test


25-1998; 5-3.3.1

Occupant use fire hose – inspection


1962-1998; 2-3.3

Occupant use fire hose – pressure   test

5-Years after installation; then   every 3-Years

1962-1998; 2-3.2

Check valve inspection


25-1998; 9-4.2.1

Pressure gauge calibration


25-1998; 2-3.2

Standpipe waterflow test


25-1998; 3-3.1

Private fire service mains


25-1998; 4-3.1

Internal inspection of system piping   (if obstruction conditions)


25-1998; 10-2.2

QR sprinkler head replacement


25-1998; 2-3.1.1

SR sprinkler head replacement


25-1998; 2-3.1.1

If you contract your sprinkler system testing and inspection activities, take this list and sit down with your contractor and review with them if they are performing these functions. The above list does not take into consideration any alternative frequencies based on the CMS categorical waivers.

If you want to download a copy of the complete list of requirements for the document review session, go to “Tools” page, and click on “Acute Care Hospital Documentation Requirements”. You will find the file under the Life Safety Document Review heading.

Next week we will look at the final installment and rest of the list of items needed for the document review session.