Inspection and Testing of Fire Sprinklers in Healthcare Facilities

Inspection and Testing of Fire Sprinklers in Healthcare Facilities

By Vincent Powers

If you are involved in the Inspection, Testing and Maintenance (ITM) of water-based fire sprinkler systems in healthcare facilities, then you are most likely familiar with Joint Commission and Centers for Medicare and Medicaid Services (CMS).  This blog will hopefully shed some light on what is required and who is the Authority Having Jurisdiction (AHJ) when it comes to these facilities.

fire sprinklers in healthcare facilities

What and who is CMS?

The CMS is part of the Department of Health and Human Services that oversees the administration of Medicare, Medicaid, and Children’s Health Insurance programs.  CMS provides status to national health care accrediting organizations to deem which healthcare facilities meet or exceed the requirements of set forth in accreditation in a specific area, in this case fire and life safety, more specifically water-based fire protection systems.

On the website  there are seven accrediting agencies that are approved by CMS with Joint Commission being one of the most widely known in the fire sprinkler industry.  Currently the 2012 edition of NFPA 101, Life Safety Code is adopted and Section 9.7.5 requires all ITM sprinkler system to be maintained in accordance with NFPA 25, The Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition.

The Joint Commission is an organization that provides a service to the CMS by evaluating a healthcare facility’s performance and providing feedback to CMS. CMS uses this information to approve funding for healthcare facilities. This is of course the abbreviated version of what CMS and Joint Commission do.

Who is Responsible for the Inspection of Fire Sprinklers in Healthcare Facilities?

Sometimes it can be confusing to determine who is the enforcer of NFPA 25 or any other NFPA standards when it comes to fire sprinklers in healthcare facilities, essentially, who is the AHJ?

Authority Having Jurisdiction; An organization, office, or individual responsible for enforcing the requirements of a code or standard, or for approving equipment material, an installation, or a procedure.

This definition is defined the same across all NFPA codes and standards and means that anyone that has the responsibility of ensuring, in this case, that all ITM requirements associated with that building’s fire sprinkler systems are completed.  Typically, the enforcement is completed by the local fire marshal or fire inspector, but this could also include but not limited to the insurance carrier, Joint Commission, and possibly the building owner.

In many cases the local AHJ will use the reports gathered by the Joint Commission inspection to satisfy the local needs and requirements as the Joint Commission usually has the means to ensure that all necessary work has been completed.  They also will make recommendations on repairs, upgrades, and maintenance of these systems to CMS.

How do the requirements of Joint Commission ITM differ from NFPA 25?

There are no differences. As stated before, CMS adopted the 2012 Life Safety Code (NFPA 101) and was effective July 5, 2016.  Additional information can be found at

The requirements typically are the same for joint commission as found in NFPA 25 ITM requirements.  Most of the difference is how the reports are requested to be presented and maintained.  Technically the only information required according to The Joint Commission on a fire protection report is the following:

  • Name of the activity
  • Date of the activity
  • Inventory of devices, equipment, or other items
  • Required frequency of the activity
  • Name and contact information, including affiliation, of the person who performed the activity
  • NFPA standard(s) referenced for the activity (including the edition and section)
  • Results of the activity

NFPA 25-2011: 4.3; 4.4;

However, most of the time it is requested that the report be prepared and separated into a binder with all systems, main drain tests, and devices divided by type. For example all wet systems would be in a section, all dry systems would be another section, then each device such as tamper switches would be in their own section.

The Joint Commission and Fire Sprinklers in Healthcare Facilities

In the end, requirements for ITM in compliance with The Joint Commission is no different than the requirements of NFPA, in fact they specifically reference NFPA standards in all of their ITM rules.  An example not necessarily found in NFPA 25 could be conducting a forward flow test on a pipe schedule system in a healthcare facility.

A Joint Commission Representative required the test be conducted a minimum of 500 gallons per minute. NFPA 25 requires the system to be flowed at a minimum of system demand. Since this was a pipe schedule system there was no hydraulic design information plate with this information.

The information can be found in NFPA 13 2010 edition Table  This table provides the system demand for light and ordinary hazards for pipe schedule systems.  Sometimes we have to think outside of the box to conform to NFPA 25, as described in the Annex section  A.1.2.

When it comes to fire sprinkler systems in healthcare facilities, the Joint Commission does not typically just pull requirements out of the air or make them up. Their requirements are based on generally accepted practices and can be found in several NFPA standards.

Additional Information for reporting.

The Joint Commission separates disciplines by Environment of Care codes, below is a link to The Physical Environment with information to each discipline such as fire sprinkler, fire alarm, dampers etc.

Below is a link to a presentation by The Joint Commission regarding ITM of several fire sprinklers in healthcare facilities.

About the Author…

Vincent Powers is the ITM Specialist for the National Fire Sprinkler Association.  During his 25 years in the fire protection industry Vince has initiated and managed several departments including inspection, testing, and maintenance, fire alarms, as well as special hazards.  His experience of fire sprinkler systems and NFPA 25 is well rounded filling the roles of technician, service manager, sales and training.

Vince holds several active NICET certifications: Level III Inspection and Testing of Water-Based Systems, Level II Fire Alarm Systems, Level II Special Hazards Systems and Level I Water-Based Systems Layout. Vince has an honorable discharge from the US Navy and resides in Maryland. Vince can be reached at