Regulation detail

K-Tag K354

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Sprinkler System – Out of Service

Jurisdiction: CM Agency: Centers for Medicare & Medicaid Services
PRTF (60%) PSYCH_FACILITY (60%) SNF (100%)
Plain-English summary

When a sprinkler system is impaired, facility operators must assess the extent and duration of the impairment, inspect affected areas, submit risk recommendations to management, and notify the fire department and other authorities having jurisdiction. If the sprinkler system is out of service for more than 10 hours in any 24-hour period, the affected building or portion must be evacuated or an approved fire watch must be maintained until the system is restored.

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Regulation text
K354 Sprinkler System – Out of Service 
Where the sprinkler system is impaired, the extent and duration of the 
impairment has been determined, areas or buildings involved are inspected 
and risks are determined, recommendations are submitted to management 
or designated representative, and the fire department and other authorities 
having jurisdiction have been notified. Where the sprinkler system is out of 
service for more than 10 hours in a 24 hour period, the building or portion of 
the building affected are evacuated or an approved fire watch is provided 
until the sprinkler system has been returned to service. 
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)