Alternate Suppression Systems for Elevator Machine Rooms
PDF Version of DQA 11-012
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Alternate Suppression Systems for Elevator Machine Rooms
The Centers for Medicare and Medicaid Services (CMS) requires the use of
the 2000 edition of the National Fire Protection Association (NFPA) 101 Life
Safety Code (LSC), which requires the use of the 1999 edition of NFPA 13,
Standard for the Installation of Sprinkler Systems.
CMS adopted a subsequent rule that requires all Long Term Care (LTC)
facilities to be retroactively sprinkler protected, over a 5 year phase-in
period, with a deadline by August 13, 2013. This rule also adopted the 1999
edition of NFPA 13.
CMS and the Department of Health Services (DHS) recognize NFPA 13 section
1-2 that permit "alternative arrangements" in lieu of water based
extinguishing systems.
Elevator machine rooms approved and installed prior to March 11, 2003 are
considered "Existing" and fall under older editions of NFPA 13
(for example: 1991, 1984, and 1980). These older editions of NFPA 13 do not
require elevator machine rooms to be sprinkler protected. Yet, given the CMS
retroactive mandate of August 13, 2013, alternative automatic supervised
extinguishment systems are permitted for these applications, and the
building remains classified as "fully sprinkler" protected.
The alternative automatic supervised extinguishing systems, when
installed in lieu of required automatic supervised water based sprinkler
protection systems, must be designed for the intended application by a
knowledgeable designer, approved by a DHS plan review, installed in
accordance with the appropriate NFPA standard, meet the manufacturer's
requirements, and be listed for the intended application. The facility shall
also maintain and test the system as required by the applicable standard,
listing, and manufacturer's requirements.
The alternative extinguishment system shall be monitored by the buildings
fire alarm system in following IBC section 904. Activation of the
alternative extinguishment system shall automatically activate the buildings
fire alarm system per NFPA 101 section 9.7.3.2.
Position: Alternative automatic supervised suppression systems are
permitted for elevator machine room applications if the elevator machine
room equipment was installed prior to
March 11, 2003.
NFPA 101 section 9.7.3.1 identifies common alternative suppression
systems - Foam (NFPA 11 and NFPA 16), Carbon Dioxide (NFPA 12), Halon (NFPA
12A), Water Spray (NFPA 15), Dry Chemical (NFPA 17), Wet Chemical (NFPA 17A)
or Clean Agent (NFPA 2001).
Reminder: LTC facilities that are not fully operational and tested
sprinkler protected by August 13, 2013 will be subject to termination. CMS,
through Division of Quality Assurance (DQA) inspections, continues to remind
facilities of the need to meet this requirement by August 13, 2013.
Please direct all questions about the content of this memo to David
Soens, Director, Office of Plan Review and Inspection at (608) 266-9675.
References:
CMS S&C Memo 09-04/Adoption of New Fire Safety Requirements for
Long Term Care Facilities, Mandatory Sprinkler Installation Requirement
http://www.cms.gov/SurveyCertificationGenInfo/downloads/
SCLetter09-04.pdf
CMS S&C Memo 03-21/Adoption of New Fire Safety Requirements for
Religious Non-medical Health Care Institutions (RNHCIs), Ambulatory Surgical
Centers (ASCs), Hospice, Programs of All-Inclusive Care for the Elderly
(PACE), Hospitals, Long Term Care, Intermediate Care Facilities for the
Mentally Retarded (ICFs/MR), and Critical Access Hospitals (CAHs) http://www.cms.gov/SurveyCertificationGenInfo/downloads/
SCLetter03-21.pdf
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Last Updated: September 30, 2011
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