Aug 23 2017

Are Smoke Barrier Doors Required to be Inspected in Hospitals?

Category: Doors,Questions and Answers,Smoke Barrier,TestingBKeyes @ 12:00 am
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Q: Do doors in smoke barriers in healthcare occupancies have to be tested and inspected? Section 7.2.1.15.2 of the 2012 Life Safety Code says smoke door assemblies have to be inspected and tested in accordance with NFPA 105.

A: Well, the answer is no… Smoke barrier doors that are non-rated are not required to be inspected annually in healthcare occupancies, even though 7.2.1.15.2 says they do. Here’s why:

  • Section 19.3.7.8 says doors in smoke barriers shall comply with 8.5.4 and all of the following: 1) Doors shall be self-closing; 2) Latching hardware is not required; and 3) The doors do not have to swing in direction of travel.
  • Section 8.5.4.2 says where required by chapters 11 through 43, doors in smoke barriers that are required to be smoke leakage-rated shall comply with section 8.2.2.4. [NOTE: Chapters 18 & 19 for healthcare occupancies do not require smoke leakage-rated doors in smoke barriers…. Therefore, compliance with section 8.2.2.4 is not required.]
  • Section 8.2.2.4(4) says where door assemblies are required elsewhere in the Code to be smoke leakage-rated, door assemblies shall be inspected in accordance with 7.2.1.15.

CONCLUSION: Since the healthcare occupancy chapters do not require smoke barrier doors to be smoke leakage-rated, then there is no requirement to be compliant with 7.2.1.15.2 that says the smoke doors need to be inspected.

Section 4.4.2.3 says where specific requirements contained in chapters 11 through 43 differ from general requirements contained in chapters 1 through 4 and from chapter 6 through 10, then the requirements of chapters 11 through 43 govern. Since the healthcare chapters do not require smoke barrier doors to be smoke leakage-rated, then it conflicts with section 7.2.1.1.5.2, and when that happens, you follow the occupancy chapter requirements.

The problem is… not all authorities having jurisdictions (AHJs) knew this or understood this. Case in point: The Centers for Medicare & Medicaid Services (CMS) had instructed their state agency Life Safety surveyors that all smoke doors in healthcare occupancies need to be tested and inspected, citing section 7.2.1.15.2.

In addition, CMS also taught their LS surveyors that doors in healthcare occupancies that meet the requirements of 7.2.1.15.1 have to be tested as well, which is not entirely true. These doors identified in 7.2.1.15.1 only have to be tested in assembly occupancies, educational occupancies, or residential board & care occupancies. The exception is, some hospitals have mixed occupancies that include the requirements for assembly occupancies, so in those cases, yes, the doors in 7.2.1.15.1 would have to be tested and inspected on an annual basis.

But on July 28, 2017, CMS issued S&C memo 17-38 which corrected this error. In this memo, CMS says smoke barrier doors do not have to be tested in healthcare occupancies. So, they saw an inconsistency with the 2012 Life Safety Code, and corrected their position. They even admitted some confusion on their part regarding door testing in general and decided to extend the date that the first fire door test is due from July 5, 2017 to January 1, 2018. But be careful with that: Not all AHJs are moving the date that the first fire door test is required.

You can expect a similar announcement from Joint Commission, if it hasn’t happened already. I’ve been told they will changed their standards to reflect what CMS has said.