There will be significant changes for facility managers to deal with when the Centers for Medicare & Medicaid Services (CMS) finally adopts the 2012 edition of the Life Safety Code. This excerpt from a new upcoming book by Brad Keyes and published by HCPro, titled “Preparing for the New Life Safety Code” discusses changes involving the life safety equipment.
According to the Life Safety Code, automatic sprinkler systems are required to be installed in agreement with NFPA 13 Standard for the Installation of Sprinklers. But NFPA 13 does not address how the sprinkler systems should be inspected, tested or maintained- just installed. Prior to 1992, NFPA attempted to identify the proper requirements for the inspection, testing and maintenance of the automatic sprinkler system in various publications, but at that time a decision was made to combine all the different NFPA standards on sprinkler inspection, testing and maintenance into one. Thusly, NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems was born, which set standards for all sprinkler systems in all types of occupancies. NFPA 25 applies to hospitals, nursing homes, ambulatory care occupancies, business occupancies and all other types of facilities, regardless whether patients are treated in the building or not. Now, there may be a question whether or not NFPA 25 is enforced by authorities at all locations, but the standard does apply to all.
The 2012 edition of the LSC references the 2011 edition of NFPA 25. The changes with NFPA 25 since the 1998 edition (which was referenced by the 2000 edition of the LSC) that are considered significant are:
- All deficiencies or impairments discovered during the inspection, testing or maintenance process must be corrected or repaired, and performed by qualified individuals
- The location of shut-off valves must be identified
- An informational sign must be placed at the system control riser supplying an anti-freeze loop, dry system, preaction system, or auxiliary system control valve. Each sign must indicate the following minimal information:
- Location of the area served by the system
- Location of auxiliary drains and low-point drains for dry pipe and preaction systems
- The presence or location of anti-freeze or other auxiliary systems
- The presence and location of heat tape
- Components and systems are permitted to be inspected, tested and maintained under a performance-based program as an alternative means of compliance, subject to the approval of the AHJ
- Vane and pressure type waterflow switches are permitted to be tested semi-annually, rather than quarterly. Other mechanical type waterflow switches must be tested quarterly
- A main drain test must be performed quarterly downstream of a backflow preventer in systems were the sole water supply is through a backflow preventer or pressure reducing valve. This is in addition to the annual main drain tests required at each riser.
- Dry sprinklers that have been in service for 10 years must be replaced, or a representative sample tested
- All sprinklers that have been in service for 75 years must be replaced, or a representative sample tested
- Standpipe hose valves (not Fire Department Connections) are required to be inspected quarterly for the following:
- Ensure hose caps are in place and not damaged
- Inspect hose threads for damage
- Ensure valve handle is present and not damaged
- Inspect gaskets for damage and deterioration
- Ensure hose valve is not leaking
- Ensure access to hose valves is not obstructed
- Standpipe systems with 2½ inch hose valves must have their valves tested annually by opening and closing the valve
- Standpipe systems with 1½ inch hose valves must have their valves tested every 3 years by opening and closing the valve
- Standpipe water-flow tests every 5 years are for wet standpipes. Dry standpipes are required to have a hydrostatic pressure test every 5 years
- Electric motor driven fire pumps are permitted to be tested monthly at no-flow conditions for 10 minutes. Engine driven fire pumps must continue to be tested weekly at no-flow conditions for 30 minutes.
The new requirement to identify the location of all shut-off valves in your sprinkler system may be accomplished many different ways: Plot them on your CAD drawings; Mark the suspended ceiling grids where the valves are located; List them on charts which are posted in conspicuous areas of the facilities department; Or do all three. Since the standard does not define how the valves are to be identified, you get to make that distinction until such time an AHJ interprets it for you.
If you are not already performing these inspections and tests, the new requirement for a quarterly main drain test downstream from the backflow preventer; and the quarterly inspections of the fire hose valves; and the annual (or 3-year) test of the fire hose valves may catch you by surprise. Make sure you begin a routine on these new inspections and tests, as the surveyors and inspectors will be fully aware of the requirements and won’t be bashful asking you for documentation.