The Importance of the “Fire Watch”

Back to News

The Importance of the “Fire Watch”

An inspection valve for a sprinkler system.

The Fire Watch is an important tool used to protect patients, staff, and visitors from the risks of a diminished fire protection system. The Life Safety Code (NFPA 101-2012, 3.3.104), defines the Fire Watch as:

“The assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occurring; extinguishing small fires, or protecting the public from fire or life safety dangers”.

CMS also provides guidance by stating:

“We believe a fire watch would consist of dedicated staff with no other duties constantly circulating throughout the facility or portion of the facility affected by the sprinkler system impairment (Federal Register (Vol. 81, No. 86); May 4, 2016).”


The TJC integrates the Fire Watch into the Interim Life Safety Measure (ILSM) process used to protect occupants during periods when specific Life Safety Code requirements are not met or during periods of construction (LS.01.02.01 EP1-15). An occupied building must be evacuated OR the fire department (or other emergency responding group) notified, and a “Fire Watch” initiated during either of the following situations (LS.01.02.01 EP2):

  • A fire alarm system is out of service more than 4 out of 24 hours
  • A sprinkler system is out of service for more than 10 hours in a 24-hour period in an occupied building.

The organization’s insurance company may also require notification. These notifications and the time period of the Fire Watch are documented.


Throughout the Fire Watch, the assigned staff should verify various building features, including:

  • Exits and egress routes remain clear of obstructions, with exit doors unlocked
  • Emergency and required lighting is functioning properly, especially in construction areas
  • Fire initiation, alarming, and suppression systems are functioning properly other than those causing the Fire Watch
  • Fire extinguishers are available, easily accessible, and in a state to function as designed
  • Appropriate signage is displayed on non-functioning fire protection equipment, altered exit, and egress routes, etc.


A Fire Watch is performed by trained personnel, touring the designated spaces on a regular basis, as described in the organization’s Fire Watch Policy; a minimum usually of hourly. The following information is documented:

  • Time of the Fire Watch tour
  • Individual(s) conducting the tour
  • Space(s) toured
  • Time each space toured
  • Status of each space(s)
  • Deficiency and corrective actions.


The Fire Watch tours data is reviewed periodically for completeness and accuracy in addition to the training provided. Closed-circuit cameras can monitor a space, but not as a substitute for personnel performing the Fire Watch tour to identify sights, sounds, and smells of combustion and fire. The Fire Watch and ILSM process is a key survey focus for accreditation organizations

Talk to an expert about your compliance needs.