The Department of Health and Human Services Centers for Medicare and Medicaid Services issued a Memorandum on July 28, 2017 to all State Survey Agency Directors  specifically addressing the fire door inspection requirements which changed with the adoption of  the 2012 version of NFPA Life Safety Codes.

centers for medicare and madicaid new fire door inspection requirements

Centers for medicare and medicaid services adoption of NFPA 2012 made it mandatory for fire doors to be inspected by qualified inspectors and proper documentation.

In the 2012 Life Safety Codes, in section 7.2.1.15 Inspection of Door Openings, and 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 notable change is that there is a new provision for the annual inspection and testing of certain fire doors and smoke door assemblies in certain certified health care facilities.

 

 

The 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-reated door 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.
  • To learn more, visit our website,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.

Also noted in the memorandum:

Asssembly occupancies, Education occupancies, day care occupancies, and residential board and care occupancies all refer to the new code adoption chapters in the 2012 LSC.

Non-rated doors, including corridor doors to patient care rooms and smoke barrier 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 teh annual inspection and testing of fire doors should be cited under K211- Means of Egress – General. 

To learn more, visit our Michigan Fire Door Inspection website.