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Automatic Fire Sprinkler Systems

Not all Ambulatory Surgical Centers are required to be equipped with an automatic fire sprinkler system, but when installed, they are effective at mitigating the severity of fires, injuries, property damage, or fatalities. However, having a sprinkler system can trigger an increase in life safety deficiencies. CMS K‐tags related to sprinkler system design, components, inspection, testing, and maintenance are consistently in the top tier of K‐tag findings for surgical centers.

There are two commonly cited K‐tags that address sprinkler systems. K351 addresses sprinkler system installation and K353 addresses sprinkler system testing and maintenance. These two K-tags are summarized in greater detail below:

Common survey findings related to sprinkler system installation (K351) include:

  • Obstructions (18” rule) – Items are not permitted to be stored within 18” of the bottom of sprinklers. This is a common problem in areas such as storage and equipment rooms. Placing items too close to a sprinkler impedes the spray pattern. 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 sprinklers directly above the storage or shelf.
  • Piping – Wire, conduit, cables, and similar items are not permitted to be attached to, supported from, or even laying across sprinkler piping. This is a common issue above a suspended ceiling.
  • Missing/Damaged or Out of Place Escutcheon Plates – Escutcheon plates are covers or trim plates that surround the sprinkler in the ceiling. The escutcheon is necessary to cover the gap between the sprinkler head and the ceiling tile or drywall and are key to the sprinkler head activating properly. Without a properly fitting escutcheon, heat and smoke can rise above the ceiling through the gap and may delay the activation of the sprinkler head.

Common survey findings related to sprinkler system inspection, testing, and maintenance (K353) include:

  • NFPA 25 (2011 edition) – NFPA 25 outlines very prescriptive inspection, testing, and maintenance (ITM) requirements for sprinkler systems. Survey findings often relate to incomplete documentation, lack of sufficient ITM practices, or lack of remediation when your vendor identifies an issue. Make sure your vendors are using the 2011 edition of NFPA 25, providing comprehensive documentation, and are notifying you if there is a problem.
  • Painted/Dirty Sprinklers – 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 will not remove easily, the sprinklers should be replaced. This should be included in the environmental rounding checklist and be addressed by a preventative maintenance activity when identified.

Automatic fire sprinkler systems are proven to save property and lives. Ensuring they are installed and maintained properly will spare you the displeasure associated with receiving a sprinkler system-related survey deficiency.

Dale Wilson, RA AIA
Project Manager