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Alternate Suppression Systems for Elevator Machine Rooms

PDF Version of DQA 11-012  (PDF, 44 KB)

Date: April 29, 2011 -- DQA Memo 11-012
To: Ambulatory Surgery Centers ASC 03
End Stage Renal Dialysis Units ESRD 03
Facilities for the Developmentally Disabled FDD 03
Hospices HSPC 03
Hospitals HOSP 04
Nursing Homes NH 07
From: David Soens, Director
Office of Plan Review and Inspections

Otis Woods, Administrator
Division of Quality Assurance

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

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 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.

CMS S&C Memo 09-04/Adoption of New Fire Safety Requirements for Long Term Care Facilities, Mandatory Sprinkler Installation Requirement

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)


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Last Updated: September 30, 2011