Author(s): Robert Solomon. Published on July 1, 2019.

In Compliance | NFPA 13

Sprinklers, state code amendments, and the safety ecosystem


For more than a year now, the NFPA community has been learning about the NFPA Fire & Life Safety Ecosystem and has been applying those concepts to a variety of problems and events. NFPA envisions the ecosystem as a series of cogs working together, and the breakdown of a single cog can result in bad things happening.

An ongoing issue in one New England state has several operators of long-term care occupancies wondering how they will get out of a jam between long-standing federal criteria and a state code provision concerning the installation of automatic sprinkler systems—a situation that involves multiple cogs of the safety ecosystem.

At the center of the problem is a state code amendment from the early 1990s prohibiting the installation of automatic fire sprinklers in elevator shafts, elevator equipment spaces, and elevator machine rooms. This amendment ran counter to the requirements in NFPA 13, Installation of Sprinkler Systems, which at the time required sprinklers in these spaces. As it happens, the facilities in question are subject to compliance surveys carried out under the authority of the US Centers for Medicare & Medicaid Services (CMS), which refers to the 2010 edition of NFPA 13. The surveys are usually done by some combination of the state health department, the state fire marshal, and a regional surveyor who works directly for CMS. In this case, the state code amendment didn’t say the sprinklers could be omitted, but prohibited them from being installed in the first place. While I cannot speculate as to why this particular issue was not flagged in previous CMS surveys at these facilities, it has become an issue in 2019.

Three of the eight cogs of the safety ecosystem include code compliance, development and use of current codes, and referenced standards. While states certainly have the right to amend model codes and standards, whether they are from NFPA, the International Code Council, or the American Society of Mechanical Engineers (keepers of the elevator code), amending them to make them less restrictive, as is the case here, has created a true conflict. While the designers, architects, contractors, and the owners whom they work for appear to have provided buildings that met the state code provisions, those facilities are nevertheless being told that they do not comply with the 2010 edition of NFPA 13, and therefore do not meet CMS requirements. And that’s where things get complicated.

The facilities in question all participate in CMS funding reimbursement programs and must meet certain evaluation criteria to qualify for the funding, including the completeness of the automatic sprinkler system and the ongoing inspection, testing, and maintenance of that system. If a noncompliance problem is identified, facilities can lose funding and they cannot admit new residents until the issue is resolved. They also cannot simply remedy the situation by retrofitting sprinklers in the elevator-related spaces, since that action would put them at odds with the state code provision as it is written.

The facilities have a few options, but each comes with a potential downside. Those options include:

» Approach the respective state building code/elevator code boards and ask for a waiver to the state code that would allow sprinklers to be installed in the elevator spaces in question. This requires the installation of a shunt trip and related detection equipment installed in accordance with NFPA 72®, National Fire Alarm and Signaling Code®. This seems to be what is done in nearly every other jurisdiction in the country without any problem.

» Apply the requirements of the 2013 edition of NFPA 101A, Alternative Approaches to Life Safety, and determine if it is possible to achieve a complying score with the noncomplying sprinkler system. For those familiar with the fire safety evaluation system used in NFPA 101A, that strategy appears to result in a deduction of two points.

» Approach the CMS regional surveyor and determine if it may be appropriate to ask for a waiver from CMS on the sprinkler issue. A potential problem with this approach could result in a withholding of federal money appropriated for the state surveys. State agencies can ill afford to turn their backs on this type of funding, which is critical to maintaining a high level of health care fire safety.

Although newer editions, including 2013, 2016, and 2019, of NFPA 13 offer specific conditions that would permit the sprinklers to be omitted from elevator shafts, equipment, and machine rooms, there is no guarantee that those conditions exist in the facilities in question. State agencies that undertake adoption and amendment of model codes need to be aware of their actions for occupancies subject to oversight by one or more federal agencies. Let’s hope that the government responsibility cog of the ecosystem can step in and resolve this unintended consequence to the satisfaction of all parties involved—most of all the residents who call these facilities their homes. 

Robert Solomon is Director of Building Life Safety, Building Fire Protection at NFPA. Top photograph: Getty Images