Enforcement Actions - Installation of Automatic Sprinkler Systems in Nursing Homes - August 13, 2013 Deadline
November 15, 2013 Revision
•Automatic Sprinkler Required in All Nursing Homes: All nursing homes must be fully sprinklered as of August 13, 2013 in order
to participate in Medicare or Medicaid.
•End of Five-Year Phase-In to August 13, 2013: The sprinkler requirement was published on August 13, 2008 in a final rule
entitled Medicare and Medicaid Programs: Fire Safety Requirements for Long Term Care Facilities, Automatic Sprinkler Systems.
The regulation provided a five-year advance timeframe to achieve full sprinkler status by August 13, 2013.
•Survey Process: While CMS is not requiring any special surveys focused on the sprinkler requirement, a life-safety code (LSC)
inspection is part of each facility’s recertification survey. As these surveys occur during the year, facilities that are
not fully sprinklered on or after August 13, 2013 will be cited for a deficiency.
•No Extensions: CMS does not have authority to allow extensions of the timeframe. CMS did issue a proposed rule on February
7, 2013 that would permit CMS to grant a time-limited extension of the due date for a facility that is building a replacement
or undergoing major modification. At present, a final rule has not been promulgated. In reviewing the plans of correction
for such facilities, we will take note of any facility that is in this circumstance. In the absence of a final rule, however,
a deficiency will still be issued if the facility is not in compliance with the regulation in force at the time of the survey.
•Attachments: Four attachments provide useful information. Attachment Three provides answers to technical questions we have
received, and Attachment Four specifies actions that a nursing home may take to substantially lower exposure to fire risks
while a sprinkler system is being installed.