Dear Administrator: Automatic Sprinkler System

Date October 22, 2009
Subject Automatic Sprinkler System

Dear Administrator:

The purpose of this letter is to provide information about the amendment of federal regulations by the Centers for Medicare and Medicaid Services (CMS) that require protection of Long Term Care Facilities by an automatic sprinkler system. Also provided is a timeline of critical dates to ensure provider compliance with the new regulations.

On March 13, 2008, CMS published a final rule announcing the amendment of regulations concerning nursing home fire safety requirements. 42 CFR 483.70(a)(8)(i) requires all nursing homes participating in the Medicare or Medicaid programs to be protected throughout by a supervised automatic sprinkler system. The regulation further requires that the sprinkler system be installed in accordance with the 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems. Compliance with this requirement must occur no later then August 13, 2013. Neither waivers nor a passing score on the Fire Safety Evaluation System (FSES) will serve as an acceptable substitute for this requirement. Please refer to S&C 09-04.

CMS concurrently adopted 42 CFR 483.70(a)(8)(ii) pertaining to the inspection, testing and maintenance of sprinkler systems and specified that these activities must be done in accord with the 1998 edition of NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.

Providers should note that CMS referenced earlier editions of NFPA 13 and NFPA 25 than those that may customarily be used by designers, installers, and maintenance and testing companies. To ensure that your system is installed in accordance with the 1999 edition of NFPA 13, and inspected, tested and maintained in accordance with the 1998 edition of NFPA 25, all contractors and consultants must be aware of the specific reference to these editions of the NFPA Standards.

Nursing homes occupying only a portion of a larger building will not necessarily require the installation of a sprinkler system throughout the entire building. CMS states the section(s) of the building requiring sprinkler protection includes all portions of the building containing the nursing home as well as any non-nursing home areas not separated from the nursing home by 2-hour fire-rated construction. In such instances, sprinkler protection must extend both horizontally and vertically until 2-hour rated construction is reached.

Consistent with Title 10 NYCRR, Providers are Required to Complete all Steps in Accordance with the Timeline Below

  • Complete the Nursing Home Sprinkler Survey, which is located on the HPN.
  • Submit a sprinkler design, funding and installation plan by June 1, 2010 if the nursing home does not currently meet the CMS requirement to the Bureau of Architectural and Engineering Facilities Planning, Hedley Park Place, 433 River Street, Troy, New York 12180. (Please note that the equity contribution for work directly attributed to the sprinkler mandate will be set at 15%.)
  • Submit a CON application by January 1, 2011 if sprinkler installation or upgrades are necessary to the Bureau of Project Management, Hedley Park Place, 433 River Street, Troy, New York 12180. Submission by the due date will allow Department review and a full 2-year period to complete final design and sprinkler installation by August 2013.

Your prompt attention to the aforementioned schedule and milestones to facilitate compliance with the CMS requirement is strongly encouraged. Questions regarding project application should be directed to Thomas Jung at (518) 402-0904. Questions regarding the regulatory requirements should be directed to David A. Bruso at (518) 408-1282.


Mark L. Kissinger
Deputy Commissioner
Office of Long Term Care


Richard Cook
Deputy Commissioner
Office of Health Systems Management