#101Wednesdays: CMS clarifies fire and smoke door inspection requirements for health care facilities

Blog Post created by gharrington Employee on Aug 16, 2017
In a #101Wednesdays post this past January, I discussed the Life Safety Code requirements for inspection of egress doors for life safety, and I touched on a bit of confusion created by the language in the 2012 edition and its adoption by the Centers for Medicare & Medicaid Services (CMS) for health care occupancies with regard to inspection of fire and smoke doors. In short, the language was formatted in such a way as to be easily misconstrued. While the language was clarified for the 2015 edition of NFPA 101, that didn’t do much to help the thousands of health care facilities (e.g., hospitals and nursing homes) mandated to comply with the 2012 edition via the CMS adoption. Staff from NFPA’s technical services division reached out to CMS and, through a series of meetings and conversations, was able relay the Code’s intent, resulting in a July 28, 2017 memorandum from CMS to the state survey agency directors clarifying the requirements for fire and smoke door annual testing. The memorandum (17-38-LSC) is summarized by CMS as follows:
· In health care occupancies, fire door assemblies are required to be annually inspected and tested in accordance with the 2010 edition of NFPA 80, Fire Doors and Other Opening Protectives.
· 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, Smoke Door Assemblies and Other Opening Protectives.
· 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 deficiencies associated with the annual inspection and testing of fire doors should be cited under K211–Means of Egress-General.
It was great to see this cooperative effort between NFPA and CMS lead to the relatively speedy issuance of this memorandum. Many facilities subject to CMS regulation and the public will benefit from this consistent, well-defined door inspection requirements. Kudos to all who worked hard to get this done! Thanks for reading, and as always, stay safe.
Got an idea for a topic for a future #101Wednesdays? Post it in the comments below – I’d love to hear your suggestions!
Did you know NFPA 101 is available to review online for free? Head over to and click on “Free access to the 2015 edition of NFPA 101.”
Follow me on Twitter: @NFPAGregH