MEDIA CONTACT INFORMATION
Kevin Doel
Public Information Manager
Office of the State Fire Marshal
800 SW Jackson, Suite 104
Topeka, KS 66612-1216
785-296-3403
kevin.doel@ks.gov


CMS Fire Door Inspection Date Change

OSFM | Aug 03, 2017

CMS has sent an update to the requirement for fire doors inspections, in health care occupancies. The original date for healthcare facilities to have their Fire Doors inspected was July 5th of 2017. CMS has now pushed back that date till January 1st of 2018. Please see below for code references to this requirement.

Although the requirements under LSC section 7.2.1.15 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 8.3.3.1, 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 8.5.4.2 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.

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.