CMS SOM App. L, Tag Q-0106

(5) When a sprinkler system is shut down for more than 10 hours, the ASC must:

(i) Evacuate the building or portion of the building affected by the system

outage until the system is back in service, or

(ii) Establish a fire watch until the system is back in service.

Interpretive Guidelines: §416.44(b)(5)

If the ASC is required to be in a sprinkler protected building, in accordance with the LSC,

the sprinkler system is a significant fire protection feature. Therefore, when a sprinkler

system is out of service for more than 10 hours in a 24-hour period, this regulation and

the LSC requires either an evacuation of the building or portion of the building affected

by the system outage, or the establishment of a fire watch until the sprinkler system has

been returned to service.

A fire watch consists of trained personnel who continuously patrol the affected areas until

the sprinkler system has been restored. The personnel must have access to fire

extinguishers and the ability to quickly notify the fire department. Fire watch personnel

look out for fire and other hazardous situations. They also ensure that fire protection

features of the building (e.g., extinguishers, means of egress, alarm systems) are available

and functioning. The fire department is to be notified any time the building sprinkler

system is out of service.

Survey Procedures: §416.44(b)(5)

If applicable, the LSC surveyors will assess the sprinkler system during the LSC survey,

but health surveyors should also assess the status of the sprinkler system at the time of the

health survey to determine if the sprinkler system has been shut down or out of service

for more than 10 hours, and if so, confirm that an evacuation or a fire watch is in effect.