The Joint Commission has reversed a change made last year in regards to standards for spare stock of sprinklers in health care facilities.

The revision revolves around Life Safety Standard LS.02.01.35, element of performance (EP) 7 for hospitals, critical access hospitals and behavioral health care organizations. 

The change would have required these facilities to store at least six spare sprinkler heads of each type and temperature rating installed in the facility. The American Society for Health Care Engineering's (ASHE) Regulatory Affairs Committee argued that this revision was a misinterpretation of NFPA 13, Standard for the Installation of Sprinkler Systems.

Two ASHE Advocacy Liaisons, Lennon Peake, PE, SASHE, and Joshua Brackett, PE, SASHE, CHFM, took the lead in working with the National Fire Protection Association (NFPA) and The Joint Commission to correct the revised standard. 

The NFPA issued a formal interpretation of the standard, prompting The Joint Commission to reverse its previous interpretation to be in line with NFPA 13 Standard for the Installation of Sprinkler System. 


Originally published Jan. 11, 2021 —

The Joint Commission has updated its standards to comply with the Centers for Medicare & Medicaid Services’ (CMS) interpretation of spare stock of sprinklers.

Although the National Fire Protection Association’s NFPA 13, Standard for the Installation of Sprinkler Systems and NFPA 25, Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems require only one of each type and rating for spare stock of sprinklers, CMS requires that six of each type and rating be provided at a minimum.

The other provisions of the NFPA standards will apply to ensure that a minimum stock of sprinkler heads, up to 24, be provided for facilities to ensure facilities have an adequate supply of stock sprinklers. According to NFPA 13 committee documents, the intent is still that these spares be provided and available on the campus and not necessarily required for each building. 

For example, if a facility has a system of over 1,000 sprinklers which contains six different types, the facility would be required to maintain a spare inventory of 36 sprinklers (six spares per type, which would total 36). However, if the same facility has only one type of sprinkler, they would be required to maintain 24 heads. The facility in this example would need to exceed The Joint Commission’s  minimum of six per type by providing 24 in total to meet the minimum requirement in NFPA 13.