Safety

Mind the gap: Measuring bottom clearances of fire-rated door assemblies

Healthcare Life Safety Compliance, November 1, 2017

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The CMS deadline for annual fire door inspections is New Year's Day 2018, but AOs aren't bound by that

By adopting the 2012 edition of the Life Safety Code® (LSC) last year as a condition of participation in the Medicare and Medicaid programs, CMS effectively adopted the 2010 edition of NFPA 80 as well. That's because, unlike the 2000 edition, the 2012 edition of the LSC requires that fire door assembles be installed, tested, and maintained in accordance with NFPA 80, which addresses fire doors and other opening protectives. Facilities that participate in the CMS programs, therefore, must ensure that their fire doors are up to spec.

The compliance deadline for annual door inspections had been July 5, 2017, but CMS postponed that deadline by nearly six months after receiving questions and pushback. As far as CMS is concerned, healthcare organizations now have until January 1, 2018, to con-duct the required annual tests of fire doors in accord-ance with section 8.3.3.1 of the 2012 LSC. That doesn't prevent an accrediting organization from moving for-ward, of course, with the original deadline, which is why experts have been advising facilities to tackle their tests as soon as possible.

The CMS memo that postponed the deadline—known formally as Memo #17-38-LSC: Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies—also clarified that smoke barrier doors aren't subject to the annual inspection and testing requirement, though even non-rated doors "should be rou-tinely inspected as part of the facility maintenance program." That means, of course, that you should track your facility's door inspections in a manner that easily differentiates between fire doors and smoke barrier doors.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Healthcare Life Safety Compliance.

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