CMS SOM App. U, Tag R230

RNCHI 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: §403.744(a)(5)

If the RNCHI 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

lookout 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:

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 out of service for more

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