CMS Clarifies Certain Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies; Extends Compliance Date

PUBLISHED: Aug 9, 2017
Relevant to: Ambulatory Care, Behavioral Health, Clinical Lab, Critical Access Hospitals, Dialysis Facilities, Hospice, Hospitals, Long Term Care, Medical Office/Clinic

The Centers for Medicare and Medicaid Services recently issued a survey and certification memorandum clarifying fire and smoke door annual testing requirements for health care occupancies. CMS adopted the 2012 edition of the NFPA Life Safety Code (LSC), which includes requirements for the maintenance, inspection, and testing of fire doors and smoke doors in certain certified health care facilities.

The 2012 LSC added new provisions under Section 7.2.1.15 – Inspection of Door Openings for the annual inspection and testing of certain fire doors and smoke doors assemblies in accordance with:

  • NFPA 80 – Standard for Fire Doors and Other Opening Protectives, 2010 Edition
  • NFPA 105 – Standard for Smoke Door Assemblies and Other Opening Protectives, 2010 Editon

The new LSC provisions under sections 7.2.1.15.1 and 7.2.1.15.2 require certain fire door and smoke door assemblies to be inspected and tested annually in accordance with the NFPA 80 and NFPA 105. However, section 7.2.1.15.1 states that these requirements only apply where required by Chapters 11 through 43. Therefore, as the LSC health care occupancy chapters (i.e., Chapters 18, 19, 20, 21) do not directly reference section 7.2.1.15, these new annual inspection and testing requirement do not apply to health care occupancies.

Annual Inspection & Testing Requirements in Health Care Occupancies

Although the requirements under LSC section 7.2.1.15 are not applicable to health care occupancies, annual inspection and testing of fire doors assemblies in accordance with NFPA 80 are still required in health care occupancies by LSC section 8.3.3.1, which is applicable to all occupancy chapters. In addition, with the exception of new doors in horizontal exits, the annual inspection and testing of smoke door assemblies in accordance with NFPA 105 is not required per LSC section 8.5.4.2 as doors in health care occupancies are not required to be smoke-leakage-rated.

Key Take-Aways:

  • In health care occupancies, annual inspection and testing in accordance with the 2010 NFPA 80 is required for all fire door assemblies.
  • Non-rated doors, including corridor doors to patient care rooms and smoke barrier doors, are not subject to the annual inspection and testing requirements of either NFPA 80 or NFPA 105.
  • Non-rated doors should be routinely inspected as part of the overall facility maintenance program as all required life safety features and systems must be maintained in proper working order.
  • LSC deficiencies associated with the annual inspection and testing of fire doors should be cited under K211 – Means of Egress - General.

Because of the confusion around this regulation CMS has extended the compliance date for this requirement by six months. Full compliance with the annual fire door assembly inspection and testing in accordance with 2010 NFPA 80 is required by January 1, 2018.

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