Compliance Date Approaches for Installation of Fire Sprinkler Systems

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Compliance Date Approaches for Installation of Fire Sprinkler Systems

By Frank Monikowski

It has been nearly three years since the Centers for Medicare and Medicaid Services (CMS) announced amended federal regulations that require long-term care facilities such as nursing homes to install a comprehensive sprinkler system in order to continue serving Medicare and Medicaid beneficiaries. The regulation from CMS, an agency in the U.S. Department of Health and Human Services, provided a five-year phase-in period (until August 2013) for long-term care facilities to be fully compliant with the fire sprinkler rule.

The regulation -- 42 CFR 483.70(a)(8)(i) -- requires the sprinkler system to be installed in accordance with the 1999 edition of NFPA 13: Standard for the Installation of Sprinkler Systems. CMS

concurrently adopted 42 CFR 483.70(a)(8)(ii) pertaining to the inspection, testing and maintenance of sprinkler systems. That regulation specifies that inspection, testing and maintenance activities be performed in accordance with the 1998 edition of NFPA 25: Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.

Approximately three million elderly and disabled Americans reside in the nation’s 16,000 nursing homes. The fire sprinkler regulations are intended to help promote fire safety and protect nursing home residents. This paper examines some of the events that led to the adoption of the fire sprinkler regulations, provides practical suggestions on how to proceed with the compliance effort, and describes the sprinkler retrofit and design/build construction processes.

The history of fire sprinklers in nursing homes

Many years back, the NFPA 13 standard allowed healthcare facilities to omit fire sprinklers in certain areas. Additionally, NFPA 101: Life Safety Code® allowed fire sprinklers to be omitted from specified areas of certain occupancies. In nursing homes, sprinklers were not typically required in resident closets and bathrooms. In older facilities built under previous fire codes, smoke detectors or fire sprinklers were often required only in hallways or higher risk areas such as storage and mechanical equipment rooms. In some cases, these fire protection devices were not required at all. Consequently, many existing nursing home structures have partial sprinkler coverage or no fire sprinklers at all, which can make these facilities more vulnerable in the event of a fire.

The issuance of the sprinkler regulations followed the tragic 2003 fires that swept through nursing homes in Connecticut and Tennessee. These homes did not have full sprinkler protection. The fires killed a total of 31 residents and injured many others. The states of Connecticut, Alabama and Tennessee subsequently put mandates in place that required non-sprinklered facilities to immediately add fire sprinklers. However, even in these states, some of the facilities considered to be sprinklered at the time the mandates were put in place may not comply today with the full sprinkler protection requirement outlined in the CMS regulation.



The 2006 editions of NFPA 101 and NFPA 5000: Building Construction and Safety Code® added provisions requiring existing nursing facilities to be retrofitted with fire sprinklers. Adoption and enforcement of these standards has not been universal, which underscores the importance of the CMS regulation.

The CMS press release that announced the new regulation back in June 2008 said the following: “CMS is taking further action to protect the lives of our beneficiaries through a more

comprehensive and effective approach to fire safety. In the past, certain older facilities were exempt from having an automatic sprinkler system, but we now will hold all 16,000 nursing homes in the nation to this standard.” According to that CMS release, there had never been a multiple-fatality fire in a facility with a sprinkler system that meets the requirements of the new rule.

A good time to take action

We are now more than halfway through the five-year phase-in period that long-term care facilities were given to be fully compliant with the new rule. With the compliance deadline on the horizon, this is an opportune time to take steps to get full fire sprinkler coverage in place in accordance with the requirements of the regulation.

A good first step in this process is an evaluation of your current sprinkler system, preferably performed by a trained professional. This evaluation can be completed by a professional fire protection engineer or a highly qualified sprinkler contractor. It is advisable to work with a firm that has NICET-certified design technicians on staff. The initial evaluation can demonstrate to a CMS representative that you are committed to due-diligence and working to get the desired results by engaging experienced professionals.

The addition of fire sprinklers could have an impact on water demand and existing pipe sizes -- another reason for hiring an experienced professional to conduct a sprinkler system survey. A copy of the original installation drawings will assist tremendously in this process. If they are not available, a sprinkler professional can do a walking review of the existing system and produce appropriate drawings. In addition, a determination will need to be made regarding the adequacy of the existing water supply and what corrective actions, if any, will be required to retrofit a new sprinkler system into the existing facility.

The value of an experienced contractor

Whether extending an existing sprinkler system or providing a new system throughout a facility, it is highly recommended that you find an experienced contactor that specializes in this type of work. Contractors experienced in sprinkler retrofits understand the importance of minimizing facility disruptions, limiting inconvenience to residents and staff, and being efficient about cleanup. They can also offer aesthetic and concealment options to fit your budget.

Two general methods are used when providing a new sprinkler system in a facility. One is the traditional method, where an architect and/or an engineer is hired to do a survey and provide



bid documents for soliciting a quote from various contractors. This process, known as design-bid-build, can be quite time consuming and some believe it delivers less overall value to the building owner. The design and development of the bid documents can be expensive in and of itself, sometimes consuming as much as 25% of the total project.

The other sprinkler system method, which we will discuss in greater detail, is design-build. With this approach, a single contract is used for design and construction. Design-build has been used for years by many quality general contractors around the country, and can be executed by skilled fire sprinkler contractors as well. It is a good fit for the type of work required when retrofitting a fire sprinkler system into an existing healthcare facility.

Design-build becomes more widely used

Design-build now represents nearly 50% of all general contracting work that is performed in the United States, according to the Design Build Institute of America (DBIA). DBIA released

information from the Construction Industry Institute (CII) on design-build performance that estimates this process can speed the completion of a project by an average of 33%. As an example, DBIA cited the federal government’s decision to proceed with design-build

methodology immediately after the 9/11 terrorist attacks on the Pentagon. DBIA reported that original estimates indicated it would have taken three years to complete the demolition and rebuilding process using design-bid-build methodology. Design-build was ultimately used, and DBIA reports that demolition and rebuilding was completed in one year [66% less time] and at a dramatically lower cost.

The pricing and retrofit process begins with a survey of the existing facility and the completion of an onsite flow test. Alternatively, you can obtain recent test information from the local water purveyor. Next, a sit-down meeting is held where the fire sprinkler contractor typically meets with facilities personnel who will be most directly involved in the sprinkler retrofit project. Sprinkler layout and concealment options are usually discussed, along with installation scheduling and the daily routines of residents and staff. The relocation of residents to temporary holding areas during the retrofit project should be given strong consideration. Others affected by the installation and any ancillary systems and any special requirements should also be discussed. The meeting can also address ceiling work, access panels, new alarms and panels, painting, soffiting, cleanup, and other renovation work considerations.

At this point, the interview process should end and a schedule developed for future meetings. Based on the interview process, and after determining the adequacy of the water supply, the fire sprinkler contractor will prepare budgetary pricing. Once that is complete, the contractor generally provides a presentation at the facility. This presentation should include the

Guaranteed Maximum Price [GMP] for the project, along with an outline specifying a list of services and products to be provided, any exclusions, and a more detailed scheduling and project management plan. The GMP should also include an estimate on any items that will need to be subcontracted to an outside vendor. The final price can then be adjusted after all



By now, the owner or facility manager should be in position to make a commitment to a contractor. If not satisfied with the presentation, there should either be an open discussion with the contractor or the meeting should end. If that happens, attention can be directed toward soliciting another contractor that may offer a better solution. Generally speaking, when retrofitting fire sprinklers in your facility, it is critical to make a good decision in the selection of a contractor. You can be best served by a contractor that has years of retrofit experience, its own design technicians with NICET certification, highly skilled construction and project

management, and the necessary staffing to get your installation completed efficiently and with minimal disruption. That is how we approach retrofit work at SimplexGrinnell. It is worth noting that a contractor capable of handling both fire alarm and sprinkler work can provide more uniformity in installation, coordination and commissioning -- and potentially a more competitive price.

After a commitment is made to a contractor via a written agreement, the contractor will proceed with a design layout. Once the layout is complete, drawings are submitted for

approval to the AHJ [Authority Having Jurisdiction] and the building owner. Simultaneously, the drawings are submitted to solicit any subcontracting quotes that may be required.

Subcontracting quotes could be needed for items such as electrical wiring for new fire alarm devices or fire pumps, painting, ceiling work or other minor general contracting activities, underground piping installation, excavation for the installation, or cleaning activities. Once bids are received, they can be reviewed by the contractor and the facility administrator or

designated party to also participate in the selection process if desired.

Once all the drawings are approved and the subcontracting process complete, the contractor’s project manager provides a detailed construction schedule and a final price is submitted. This schedule will include all subcontractors, what areas need to be worked during off hours -- such as kitchen and dining areas -- and daily, weekly and monthly projections.

The scheduling is critical, and buy-in and cooperation will be needed from all affected parties. An experienced sprinkler foreman and project manager can work to ensure a smooth flow of required daily operations. Preparing for the unexpected and being able to shift to other areas when an emergency arises are paramount in maintaining the schedule and providing a smooth transition for residents and facility staff. Neat and clean workmanship will assist in getting residents back in their rooms comfortably and safely. The proper equipment, whether for hole drilling or covering of furnishings, can also help simplify the process and the daily cleanup. Finally, when all installation is complete, a training session with facility maintenance and key administrative personnel should be conducted. This training should include daily, weekly, and monthly sprinkler requirements, an explanation of the functional operation of the systems, and a binder with operation and maintenance manuals, together with a copy of NFPA 25, the standard for maintaining water-based fire protection systems.

Testing, inspection and maintenance of fire sprinkler systems



responsibilities outlined in NFPA 25: Standard for the Inspection, Testing, and Maintenance of

Water-Based Fire Protection Systems. The importance of proper inspection, testing and

maintenance is described in the standard itself: “History has shown that the performance reliability of a water-based fire protection system under fire-related conditions increases where comprehensive inspection, testing, and maintenance procedures are enforced.”

The standard lays out the responsibilities of building owners in maintaining their sprinkler systems, the basic requirements for properly inspecting and testing sprinkler systems and their components, and the steps that should be taken when system deficiencies and impairments are found. There are experienced and respected companies (such as SimplexGrinnell) that can help nursing homes in fulfilling the NFPA 25 inspection, testing and maintenance requirements and in keeping their systems compliant and in good working order.

Frank Monikowski is the Fire Sprinkler Marketing Manager for SimplexGrinnell , a full-service sprinkler and fire alarm contractor that also provides integrated security, emergency




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