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Most-cited standards in 2018 show you need to check your sprinkler heads


June 1, 2019

By A.J. Plunkett (aplunkett@decisionhealth.com)

In case you were wondering, surveyors for The Joint Commission (TJC) are still inspecting sprinkler heads for dust, dirt and damage. And still finding it. A lot of it.

Be prepared to replace sprinkler heads if TJC finds the dirt or damage is enough to potentially cause a high likelihood for harm, a category under the SAFER Matrix scoring that could ultimately threaten your accreditation status if enough requirements for improvement (RFI) pile up.

Violations under Life Safety standard LS.02.01.35, which requires hospitals to provide and maintain fire extinguishing systems, led all standards for the most RFIs in 2018. A whopping 88.85% of the 1,460 hospitals surveyed in the annual roundup of top challenges were cited under that standard, according to TJC’s April issue of Perspectives.

Critical access hospitals did only marginally better — 84.93% of the 146 hospitals that faced accreditation surveys received RFIs under the standard.

During the commission’s annual Executive Briefing held last fall, TJC executives said problems with sprinkler heads cited under LS.02.01.35, EP 5—which requires sprinkler heads to show no damage and be “free from corrosion, foreign materials, and paint and have necessary escutcheon plates installed”— ranked third on the list of LS problems identified with a high likelihood to cause harm.

Are your sprinklers ‘loaded?’

The concern is that dirty or damaged sprinkler nozzles may not activate or may do so too slowly in the event of a fire, according to NFPA 25, the “Standard for the Inspection, Testing and Maintenance of Fire Extinguishing System,” which is reference by TJC for information on sprinkler heads.

The NFPA 25 notes that sprinklers “loaded” with dirt, dust, paint or corrosion can have a “detrimental effect on the performance,” including hindering or changing water spray distribution or insulating the thermal elements inside the nozzle that signal the sprinkler to activate, delaying operation or stopping it all together.

“Severely loaded or corroded sprinklers should be rejected as part of the visual inspection,” states NFPA 25. Such sprinklers must be replaced.

However, NFPA 25 states also that if the sprinkler is “loaded with a coating of dust, it is permitted to clean sprinklers with compressed air or by a vacuum provided that the equipment does not touch the sprinkler.”

In order to deal with problematic sprinkler heads immediately you must also have spares at the ready to switch out, say fire safety experts. The requirement can be found in NFPA 25, Chapter, as well as under EP 7 of LS.02.01.35.

Check your replacement parts

If you use a sprinkler head to replace a damaged or loaded nozzle, make sure to replenish your supply. The number and type of spare sprinkler heads you need to have on hand depends on the size of your fire extinguishing system.

How fast you can find replacement nozzles depends on the age of your fire sprinkler system, says Jason Hugo, owner of Quick Response Fire Supply (QRFS) in Athens, Ohio.

While there has been a backlog of parts for fire doors and other equipment as hospital facilities have worked to come in line with expectations under the NFPA 101-2012 Life Safety Code® adopted by CMS in 2016, there is no backlog for sprinkler nozzles, says Hugo.

However, the older a hospital facility or sprinkler system is, the longer it might take to find a part that can work with that system, he notes. Or if a sprinkler manufacturer has gone out of business or merged with someone else, it may take longer to identify the replacement part.

NFPA 25 requires new and listed sprinklers to replace existing sprinklers—no swapping from one area to another—and “sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property.” And special or quick—response sprinklers have even more replacement requirements under the standard.

There is always the possibility that your facility is so old that the sprinkler system is basically obsolete, warns Hugo. In that case, “no amount of digging” is going to find a replacement part to fit it, he says.

But that doesn’t mean you have to upgrade your entire fire extinguishing system. You might have to upgrade parts of it in order to meet NFPA requirements, according to a QRFS blog on “How to replace an obsolete sprinkler head or component,” found on the company’s website. Another blog posting offers a step-by-step process, with photos and graphics, to help identify your system’s manufacturer and the needed part. website (see links in Resources).

Be prepared for RFI

No matter how prepared you are, be ready to take an RFI under LS.02.01.35, warns Steven MacArthur, a former hospital safety officer and now a senior consultant with The Greeley Company in Danvers, Mass.
That TJC requirement is likely to top the list of most challenging standards for the near future, he says.

Along with the new LSC requirements, TJC changed how it scored surveys, switching from a system that designated some EPs as more serious than others. Category “A” EPs were an automatic RFI, while hospitals had to rack up three or more Category “C” EPs under a standard for an RFI finding.

Now RFIs are ranked along the SAFER matrix continuum.

 “Truth be told, the real tipping point on this one was back a couple of years ago … when they did away with the ‘C’ elements of performance,” says MacArthur in an email. “Now, they only have to find one issue relative to the sprinkler system and that’s enough for an RFI.”

“Dust on one sprinkler head—finding! One missing escutcheon ring—finding. Paint or a bit of joint compound or some plastic on a sprinkler head—finding! One network cable resting on top of a sprinkler pipe—finding!”

Prepare to take a finding by staying vigilant in inspecting sprinkler heads and systems. And be ready to switch out parts when needed during survey to help mitigate the severity of the problem.

“It is almost impossible to make sure that everything is perfect with this stuff every minute of every day—buildings just don’t work that way,” says MacArthur. “The only thing you can do is to try and keep up with the stuff as best you can, with the understanding that, unless you are pretty freaking fortunate, over the course of a survey, they’re going to find something.”



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