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 6.2.9.7, 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.

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.