Just a few days removed from Annual fire Prevention month, we want to make sure that facilities have not forgotten about the Testing of Fire Door Assemblies that became effective for compliance by CMS in January 2018. The guidance in Survey and Certification 17-38-Life Safety Code (LSC) requires organizations to inspect and test fire door assemblies in accordance with National Fire Protection Agency (NFPA) 80, 2010.
The CMS adoption of LSC©101, 2012 added some new language under Section 220.127.116.11 (Means of Egress) related to Inspection of Door Openings; annual inspection and testing of certain fire doors and smoke door assemblies.
The American Society for Healthcare Engineering (ASHE) Handbook on Inspecting, and Maintaining Swinging Doors is a good start for training staff. Staff must, according to Section 18.104.22.168.5, of the LSC, demonstrate knowledge and understanding of the operating components of the type of door being subjected to testing. Any deficiencies associated with the annual inspection and testing of fire doors will be cited under K211 – Means of Egress from the CMS perspective.
The Joint Commission standard at EC.02.03.05, EP25 related to fire door assembly testing became effective on March 11, 2018. The annual fire door assessment will also contribute to the Joint Commission expectations under LS.01.01.01, EP2 for completing a building assessment to demonstrate compliance with the LSC.
Stay tuned as C&A will continue to bring you information that needs to stay on your organization’s radar.
Sources: NFPA80, 2010, Standard for Fire Doors and Other Opening Protectives,
NFPA 105, 2010, Standard for Smoke Door Assemblies and Other Opening Protectives.
NFPA 101, 2012, Life Safety Code©
The Joint Commission Standards, 2018
CMS- Survey and Certification Letter (S&C) 17-38-LSC, released July 28, 2017