CMS Fire and Smoke Door Annual Testing Requirements Update Memo

CMS Fire and Smoke Door Annual Testing Requirements Update Memo

Fire and Smoke Door Annual TestingCMS Fire and Smoke Door Annual Testing Requirements Update Memo

On Friday, July 28th the Center for Medicare & Medical Services (CMS) released a memo addressing some of the confusion about the new codes that went in to effect July 5, 2016. Just over a year later, questions were still surrounding the new requirements.

Prevent responded to the memo with the following that went out to all customers about the fire and smoke door annual testing:

At first, our Prevent sales representatives were flooded with questions about finding a qualified person to inspect and repair their fire doors. We were able to answer your questions in our blog post, How to Choose a Qualified Fire Door Inspector.

More recently the question that we have been receiving is regarding which doors fall under the new code. Last week’s CMS memo offers the following clarification:

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.

Fire door assemblies will need to be inspected and tested annually with the documentation to support it (See The No. 1 Reason Fire Doors Fail Inspection). However, all other doors should be on a regular maintenance schedule to ensure that each one is working properly. They will be spot-checked when the Joint Commission comes in to survey your facility and if there are too many doors that are not latching and closing, you can be cited.

Of course, deficiencies can be avoided with a proper maintenance plan. Prevent Life Safety has you covered every step of the way. Due to the overwhelming confusion of the new requirements, the CMS has extended the compliance date to January 1, 2018, so now is the time to get a good plan in place. Our Fire Barrier Management programs are custom-made for each facility’s needs.


The life safety specialists at Prevent have you covered for all of your fire barrier component service needs. Call 1-877-392-6074 to discuss your compliance or request a free quote online.

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