Q: Joint Commission recently posted a revision to LS.02.01.35 EP7 stating in part "at least six spare sprinkler heads of each type and temperature rating installed in the facility are readily available". This revision seems to go against both NFPA 13 (2010) & NFPA 25 (2011), both of which have listed "total" number of needed spares based on overall head inventory, and in the annex section, clearly states "two" spares of each type (not six as listed in the TJC EP). Has this conflicting info come up yet? As part of a large building, with many different types of heads, the change to six spares of each type will be a significant change.

A: You are correct in saying NFPA 25-2011, section A.5.4.1.4 only requires a minimum of two sprinklers of each type and temperature rating installed in the building should be provided as spares. But the online bulletin from The Joint Commission says their new standard LS.02.01.35, EP 7 will now require six (6) spare heads of each type and temperature rating be stocked as spares. Why did TJC jump and require six (6) spare heads of each type and temperature, rather than stay with what NFPA requires? Apparently, they are taking note of a change in NFPA 25-2020 section 5.4.1.5 that NFPA made that requires six (6) spare heads of each type and temperature rating. But that is odd as The Joint Commission is not required to write their standards according to the 2020 edition of NFPA 25. They are required to comply with the 2011 edition of NFPA 25.

I don’t know what their motivation or reason was but it is important to remember that The Joint Commission is an authority having jurisdiction (AHJ), and they can require their clients to hold to a higher standard than what the minimum NFPA requirements do. So, it is well within their right to require this.

What should hospitals do? Well, hospitals should update their Spare Sprinkler List to determine if they have at least six (6) spare heads of every type and temperature rating installed in their building, make changes where necessary, and keep their current stock and use it as needed. If the spare heads are stored properly, there is no need to replace the heads simply due to age.

Also, since CMS and the other accreditation organization have yet to require more than two (2) spare heads of each type and temperature, this change only applies to The Joint Commission accredited organizations.

It is not the first time that The Joint Commission has required their clients to hold to a higher level of standard than what NFPA requires, but it is not that common either. With very few exceptions, CMS only requires what the adopted editions of NFPA codes and standards say, and for the accreditation organization to go above and beyond what CMS requires is unusual. I suggest you make your displeasure known to the accreditor.