Q&A: Fire alarm systems and sprinkler systems (LS.02.01.34 and LS.02.01.35)

February 12, 2026
Accreditation & Quality Compliance Advisor
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Q: What are some tips to stay compliant with our fire alarm and sprinkler systems?

A: Ask to review your facilities department vendor inspection records on the fire alarm system and the sprinkler system. Take time to look specifically for any notations as such, ask the facilities department for follow-up documentation that the devices were actually repaired or replaced.

Always support efforts by your organization to install sprinklers in places where they are not already installed. The added benefit for patient safety and the reduced expenses in time and resources will far outweigh all up-front costs.

Take a tape measure with you during rounds, and check for the proper 18-inch clearance underneath sprinkler heads. Take a look at fire extinguishers during rounds. They must be inspected once per month, but The Joint Commission says it can be any time during the calendar month, not exactly 30 days between inspections.

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Accreditation & Survey Preparation

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