Center for Clinical Standards and Quality/Survey & Certification Group

REPOSTED FROM THE DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-16
Baltimore, Maryland 21244-1850

Ref: S&C 17-38-LSC
DATE: July 28, 2017
TO: State Survey Agency Directors
FROM: Director
Survey and Certification Group
SUBJECT: Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies
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.
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.
Page 2 – State Survey Agency Directors
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.
Contact: If you have questions concerning this memorandum, please send them to
[email protected].
Effective Date: Immediately. This policy should be communicated with all survey and
certification staff, their managers and the State/Regional Office training coordinators within 30
days of this memorandum.
/s/
David R. Wright
cc: Survey and Certification Regional Office Managemen