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CMS Details New Annual Testing Requirements for Fire & Smoke Doors

September 20, 2017 David Spence Jump to Comments

If you didn't get the memo, be advised that the Center for Medicare and Medicaid Services has updated it's requirements for annual testing of fire and smoke doors in healthcare facilities. Here are the new requirements and guidance pulled directly from the memorandum that accredited agencies will be on the lookout for starting the first day of 2018:


Memorandum Summary
• In health care occupancies, fire door assemblies are required to be annually inspected and tested in accordance with the 2010 National Fire Protection Association (NFPA) 80.
• In health care occupancies, non-rated doors assemblies 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 facility maintenance program.
• Full compliance with the annual fire door assembly inspection and testing in accordance with 2010 NFPA 80 is required by January 1, 2018.
• Life Safety Code (LSC) deficiencies associated with the annual inspection and testing of fire doors should be cited under K211 – Means of Egress - General.

Background
The Centers for Medicare & Medicaid Services (CMS) adopted the 2012 edition of the NFPA 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 the 2010 editions of NFPA 80 – Standard for Fire Doors and Other Opening Protectives, and NFPA 105 – Standard for Smoke Door Assemblies and Other Opening Protectives.

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.

It should be noted that the LSC chapters for assembly occupancies, education occupancies, day care occupancies, and residential board and care occupancies do directly reference 7.2.1.15. Therefore, if a health care occupancy contains a separated multiple occupancy, the 7.2.1.15 requirement for annual fire and smoke door inspection and testing would be applicable to these other 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.

Conclusion
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. But, non-rated doors should be routinely inspected as part of the 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.

Compliance Time Extension
CMS regulatory adoption of the 2012 LSC regulation was July 5, 2016, therefore the required annual door inspections and testing would be expected by July 6, 2017. However, considering the level of reported misunderstanding of this requirement, 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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