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There has been some confusion with The Joint Commission’s new revisions on standard LS 02.01.35 EP 7 because it seems like the same old standard in an abridged manner. So what are the changes? It’s basically the current standard with a tiny but important tweak.
Standard LS 02.01.35 EP 7 previously stated you must have at least 6 spare sprinkler heads located in your fire sprinkler box with wrenches stored within the cabinet. Additionally, the cabinet must be stored in an area that is less than 100 degrees Fahrenheit.
The new changes to the standard starting January 1, 2021 are you must now have at least 6 sprinklers of EVERY TYPE of sprinkler head that is present within your facility. This means that many organizations will have to increase their capacity since they only possess a couple of each type of head. You will still have to adhere to the prior standard as well as ensuring that wrenches are located in each box and stored in an area that is less than 100 degrees Fahrenheit.
Hopefully, this short article helps clarify the changes in the standard. While surveying, I noticed some of you have been proactive and do not have to change anything. As a form of checks and balances, I would check them again to make sure all the sprinkler heads are present in your box since that will be a survey focus of your accreditation agency.
As always if you have any questions, please do not hesitate to contact me. I am always more than happy to help clarify any questions you may have!
The Compliance Survey Dashboard is a program that helps you not only transition to 100% electronic documentation but gives you the ability to immediately check where you are in your regulatory testing at the touch of a button.
September 20, 2021
Presenters: Lance Wolf, Clayton Smith, John Schmidt, and Craig Elliott
May 5, 2021
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