In a memorandum released in July 2017, The Centers for Medicare & Medicaid Services (CMS) confirmed that in addition to the new requirements for fire and smoke door testing, they are extending the deadline for compliance to January 1, 2018. What follows is the text of the memorandum.
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 220.127.116.11 – 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 18.104.22.168.1 and 22.214.171.124.2 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 126.96.36.199.1 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 188.8.131.52, 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 184.108.40.206. Therefore, if a health care occupancy contains a separated multiple occupancy, the 220.127.116.11 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 18.104.22.168 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 22.214.171.124, 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 126.96.36.199 as doors in health care occupancies are not required to be smoke-leakage-rated.
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.