Dec 11 2017

Generator Testing

Category: Generators,Questions and Answers,TestingBKeyes @ 12:00 am

Q: In a business occupancy and an ambulatory occupancy do we need to test our generator on load each month or can we do a load bank test once per year?

A: Yes… Monthly load tests are required for emergency power generators at ambulatory healthcare occupancies and business occupancies. According to the 2012 Life Safety Code, sections 20/ for ambulatory healthcare occupancies and 38/39.5.1 for business occupancies, compliance with section 9.1 on utilities is required (just like healthcare occupancies).

Section 9.1.3 requires compliance with NFPA 110-2010 regarding emergency power generators, and section 8.4.1 of NFPA 110 requires monthly load tests.

Now… there is an exception to all of these testing requirements…. Section 9.1.3 says emergency generators, where required for compliance by the LSC, must be tested and maintained in accordance with NFPA 110-2010. So, if you are not required to have emergency power generators at the ambulatory healthcare occupancy or the business occupancy, then you do not have to maintain them according to NFPA 110.

Oct 24 2017

Fire Door Testing

Category: Fire Doors,LSC,Questions and Answers,TestingBKeyes @ 12:00 am

Q: Now that we have some clarification from CMS on annual door inspection [See CMS S&C memo 17-38, dated July 28, 2017], I wanted to see if there was any new interpretation on rated corridor doors (20 minute and up) that are installed in non-rated wall assemblies. In looking at most publications from different authorities, they have interpreted that all rated doors need to be annually inspected since it could be obvious to the public. Section of the 2012 Life Safety Code says existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. However, section says where specific requirements contained in Chapters 11 through 43 differ from general requirements contained in Chapters 1 through 4, and Chapters 6 through 10, the requirements of Chapters 11 through 43 shall govern. If the chapters 11-43 govern over chapters 1-10 why are the authorities not recognizing where it states compliance with NFPA 80 shall not be required? Unfortunately, it doesn’t say this for “smoke barrier” doors, so the authority’s logic could still have reason. In my interpretation of and reading the appendix it seems that NFPA is referring to first response Life Safety features, like a pull station, fire extinguisher, strobe lights, fire panels etc….. If Joe Public is seeing a fire door do its thing, it’s probably too late. Certainly, first response LS features should always work even if they are not required.

 A: You make many excellent points. But the way I see it (and interpretations by most of the AOs and CMS agree), section of the 2012 LSC requires compliance with NFPA 80 for fire doors and windows. There are no exceptions in that exclude fire-rated doors located in non-fire-rated barriers. Compliance with is required by section Where section says compliance with NFPA 80 is not required, they are speaking about non-fire-rated corridor doors, which are in smoke partitions that separate a corridor from another area or room.

Smoke barrier doors are often not corridor doors; they are cross-corridor doors. But at times, a smoke barrier can (and does) include a corridor wall and what appears to be a corridor door is now also a smoke barrier door. In those situations, the hospital has to comply with the most restrictive requirements.

To me, it is plain: If you have a fire-rated door (regardless if it is located in a fire-rated barrier or not), then it must comply with NFPA 80 and you must test and inspect it on an annual basis.  I’ve been told that the opinions from the staff at NFPA do not agree with this, but NFPA does not enforce the LSC, so we need to comply with those interpretations made by the authorities who enforce the Life Safety Code, such as CMS and the AOs.


Sep 28 2017

Testing of Smoke and Fire Doors

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am

Q: With regards to the 2012 edition of the Life Safety Code and the requirement to perform annual inspections of smoke/fire doors, would it be safe to assume that annual for “year one” would be between August 2016 and August 2017 and even beyond if we apply the +/- days to the annual requirement? We are having trouble trying to get everything done am hoping we can push out the new annual door inspection tasks.

A: First of all, I do not believe that smoke doors in healthcare occupancies are required to be inspected. Yes… section of the 2012 LSC says (in part) smoke door assemblies need to be tested. But that conflicts with the occupancy chapter for healthcare and section says when specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the occupancy chapter shall govern. Section says doors in smoke barriers shall comply with section 8.5.4. Section says where required by chapters 11 – 43 doors in smoke barriers that are required to be smoke leakaged-rated, must comply with section (which requires testing). Chapters 18 & 19 (healthcare occupancies) do not require smoke doors to be smoke leakaged-rated: Therefore, smoke barrier doors do not have to be tested in healthcare occupancies.

Now… you may have a state agency that believes differently. Ultimately, they are an authority and if they say you have to test smoke doors, then you have to test smoke doors. But it is not required in healthcare occupancies according to the 2012 LSC. Also, some authorities say that healthcare occupancy doors in must be tested, even if they are not fire-rated doors. This also is incorrect. The doors identified in do not apply to healthcare occupancies so they are exempt from having to be tested. Only doors in assembly occupancies, educational occupancies, and residential board & care occupancies need to comply with

But be aware: If you have areas of your healthcare facility that qualify as assembly occupancy, even if you do not declare that area as assembly occupancy, then you must comply with and test those doors. This would include doors in assembly occupancies that:

  • Have panic hardware or fire-rated hardware;
  • Are located in an exit enclosure;
  • Are electrically controlled egress doors;
  • Delayed egress, access-control, and elevator lobby locked (per

Secondly, CMS has stated that they require the first test/inspection of the fire doors to be completed by July 5, 2017. This date is based on the effective date of the 2012 Life Safety Code (which was July 5, 2016), and the fact that the fire door testing is an annual event. So, the first annual inspection is not due until July 5, 2017. I know the Accreditation Organizations will follow suit.

By the way… CMS has stated they do not approve of the ‘+’ portion of due dates. In other words, if the accreditation organization says annual means 12 months from the previous test, plus or minus 30 days, CMS is saying they do not approve of the ‘plus 30 days’. They don’t mind the ‘minus 30 days’ but they do not approve of any test/inspection going beyond what is required for a due date.

Sep 20 2017

Fire Door Annual Test & Inspection

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am

Q: I’d like some clarification concerning the new requirement for annual fire door inspections: NFPA 101 2012, Chapter States “Where required by Chapters 11 through 43, the following door assemblies shall be inspected ….”. I haven’t found anything in Chapters 18 or 19 that specifically require the annual inspection. Additionally, the NFPA 101 Handbook specifically states that only occupancies requiring inspections are Assembly, Educational, Day-Care and Residential board and care. My question is where is the specific reference that is requiring hospitals to conduct annual fire door testing?

A: What you stated was actually section which does not refer to fire-rated doors, but to certain doors in high-traffic areas, or doors of high importance, such as doors equipped with panic hardware, doors in exit enclosures, electrically controlled doors, or doors with special locking arrangements. Now some of these doors may be fire-rated, but section does not specifically refer to fire-rated doors. Therefore, that is why this section is only required if the occupancy chapter requires it and you’re correct in saying the healthcare occupancies do not require it.

And you’re correct: These doors are only required to be tested in occupancies where the occupancy chapter specifically requires it. The healthcare occupancy chapters and the ambulatory healthcare occupancy chapters and the business occupancy chapters do NOT require it, so the test and inspection identified in are not required in healthcare, ambulatory healthcare, and business occupancies. Now, if you have mixed occupancies in your hospital and have areas that could qualify as assembly occupancy (i.e. dining areas, auditoriums, large conference rooms, etc.) then you would have to make sure the doors identified in are tested and inspected in those areas.

But look at section which refers to fire-rated doors and at the end of this section, it says “See also Section”. Section requires openings that are required to have a fire-protective rating (i.e. fire-rated doors) shall be protected, by approved, listed labeled fire door assemblies with the requirements of NFPA 80. Since NFPA 80 requires annual test and inspections of all fire doors, this is the section (not that requires you to test and inspect your fire-rated doors.

The CMS S&C memo 17-38 which was issued on July 28, 2017, describes this issue as well. CMS re-adjusted their expected completion date for the first fire-door test and inspection from July 6, 2017 to January 1, 2018, but not all of the Accreditation Organizations followed suit. Check with your authorities having jurisdiction to confirm what date they are expecting you to complete your first fire-door test and inspection.

Sep 07 2017

Monthly Test vs. Weekly Test of Fire Pumps

Category: Fire Pump,Questions and Answers,TestingBKeyes @ 12:00 am

Q: Electric fire pumps needed to be run once a week. Then that was changed to once a month. Now the new NFPA 25 has the pump being run once a week again. Is this correct? If my AHJ has adopted the most current code I need to follow that code and change my pump running from once a month back to weekly schedule?

A: Let’s look at the facts: The 2000 Life Safety Code referenced the 1998 edition of NFPA 25, which required all electric motor-driven fire pumps to be tested at no-flow on a weekly basis. The 2012 Life Safety Code references the 2011 edition of NFPA 25 which permits electric motor-driven fire pumps to be tested at no-flow on a monthly basis (see of NFPA 25-2011).

Section of the 2014 edition of NFPA 25, says: “Except as permitted in and, a weekly test frequency shall be required for the following electric fire pumps:

  • Fire pumps that serve fire protection systems in high rise buildings that are beyond the pumping capacity of the fire department;
  • Fire pumps with limited service controllers;
  • Vertical turbine fire pumps;
  • Fire pumps taking suction from ground level tanks or a water source that does not provide sufficient pressure to be of material value without the pump.


Section says a monthly test frequency shall be permitted for electric fire pumps not identified in section; and section says monthly test frequency shall be permitted for electric fire pump systems having a redundant fire pump. So… since CMS adopted the2012 Life Safety Code on May 4, 2016 with an effective date of July 5, 2016, CMS and all of the accreditation organizations are on the 2011 edition of NFPA 25 which permits all electric motor-driven fire pumps to be tested monthly, without exceptions.

However, if one of your other AHJs adopted a more recent edition of the Life Safety Code that references the 2014 edition of NFPA 25, then you have an obligation to comply with the most restrictive requirements, which may be a weekly test of your fire pumps, if section of NFPA 25-2014 applies to you.

In anticipation of your next questions, I do not know what “Fire pumps with limited service controllers” mean. If that is an issue for you, I suggest you contact your AHJ that is requiring you to comply with the 2014 edition of NFPA 25 and ask them to define it.

Aug 23 2017

Are Smoke Barrier Doors Required to be Inspected in Hospitals?

Category: Doors,Questions and Answers,Smoke Barrier,TestingBKeyes @ 12:00 am

Q: Do doors in smoke barriers in healthcare occupancies have to be tested and inspected? Section 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 says they do. Here’s why:

  • Section 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 says where required by chapters 11 through 43, doors in smoke barriers that are required to be smoke leakage-rated shall comply with section [NOTE: Chapters 18 & 19 for healthcare occupancies do not require smoke leakage-rated doors in smoke barriers…. Therefore, compliance with section is not required.]
  • Section says where door assemblies are required elsewhere in the Code to be smoke leakage-rated, door assemblies shall be inspected in accordance with

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 that says the smoke doors need to be inspected.

Section 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, 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

In addition, CMS also taught their LS surveyors that doors in healthcare occupancies that meet the requirements of have to be tested as well, which is not entirely true. These doors identified in 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 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.

Aug 04 2017

Sprinkler Testing Certification

Category: Questions and Answers,Sprinklers,TestingBKeyes @ 12:00 am

Q: I reside in California. Do I need a special license or certificate to perform monthly and quarterly sprinkler systems tests and/or inspections? Primarily, I am interested in main drain tests. I am the fire alarm, technician at a large hospital, and have NICET Level II certification. I have over 20 years of hospital fire experience and I have a State of California weekly fire pump test certificate. From a NFPA standpoint, do I need a license or certificate to perform testing and inspections on water based fire protection equipment (sprinklers)?

A: No. NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems only requires ‘qualified’ people to perform the inspections and testing activities, and ‘qualified’ means being competent and capable, and having met any requirements and training that are acceptable to the AHJ. So, if the state of California has additional requirements for training, such as licensing and/or certification, then you would have to comply with that. But NFPA 25 does not require license or a certificate to perform inspections and testing.

Jul 27 2017

AHJ on Fire Door Inspections

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am

Q:  Does the authority having jurisdiction have the final say whether or not an individual has the ‘knowledge and understanding’ required to perform fire door inspections?

A: Yes they do. Take a look at of the 2012 LSC “The authority having jurisdiction shall determine whether the provisions of this Code are met.” That means the AHJ decides if the organization is compliant with the applicable NFPA codes and standards. But, keep in mind the typical hospital has 5 or 6 different AHJs that inspect their facility for compliance with the LSC:

  • CMS
  • Accreditation organization
  • State health department
  • State agency with over-sight on hospital construction
  • State fire marshal
  • Local fire inspector
  • Liability insurance company

Not one AHJ can over-ride another AHJ’s decision. All AHJs are equal… but different. If 5 AHJs say the qualifications of the person performing the fire door inspections are fine, but 1 AHJ says no, then the hospital must comply with the most restrictive requirements and comply with the latter AHJ’s desires. An AHJ may have rules and requirements that exceed NFPA standards, as well they should. NFPA standards are minimal standards, and most hospitals exceed the NFPA standards in some capacity, often due to local ordinances or state regulations (and sometimes at the whim of the design professional). But, if the AHJ decides to have standards that exceed the minimal NFPA requirements, they need to be able to justify that decision.

It is not at all uncommon for a healthcare organization to seek permission from a state or local AHJ (i.e. state fire marshal) to install a particular device or have a particular feature, only to find out later that their accreditation organization does not agree, and cites the issue. Both the state or local AHJ and the accreditation organization are correct; they are interpreting the Life Safety Code as they see fit. Whatever was approved by the state or local AHJ is just an approval for the state or local regulations. What was cited by the accreditation organization was cited based on the accreditation organization’s regulations and understanding of the Life Safety Code.

This is why healthcare organizations need to obtain permission and interpretations from all of their AHJs… not just one or two.

Jul 20 2017

Fire Door Inspection Qualifications

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am

Q: In regards to fire door inspections, what are the qualifications of the person to perform the inspection?

A: NFPA 80-2010, section says fire doors must be tested by individuals with knowledge and understating of the operating components of the door assembly, but NFPA 80 does not identify or describe what ‘knowledge and understanding’ actually means. The word ‘qualified’ is not found in this context of describing the individual who performs this inspection. When the codes or standards are vague (as they often are), then it is up to the authorities having jurisdiction to decide how to interpret the code or standard (see of the 2012 LSC). When the AHJ does not make an interpretation of the code or standard, then it is up to the individual facility to decide what’s right.

In this case, no national AHJ has published an interpretation for hospitals on what ‘knowledge and understanding’ is required to test and inspect fire door assemblies. Therefore, hospitals and other healthcare organizations have the right to decide what that means. However, during a survey or an inspection, the AHJ surveyor has the right to question how the hospital determined their individual has the ‘knowledge and understanding’ and if it is not satisfactory to the AHJ surveyor, then a citing may be in order.

My advice to healthcare organizations on this issue is to document why they believe their individual has the ‘knowledge and understanding’ to perform the inspections. If their maintenance person has worked on fire doors for 20 years then that may be sufficient evidence.

I also recommend healthcare organizations to sign their people up for an online course on fire door inspections, by using the link and coupon code located at the right-hand side of this web-page, to the International Fire Door Inspector Association (IFDIA).

Jul 19 2017

Maintaining Testing/Inspection Documents

Category: Documentation,Questions and Answers,TestingBKeyes @ 12:00 am

Q: Our organization is accredited by Joint Commission. I know for inspection purposes we need to have the current year plus that past three years of documentation for LS and EC standards such as fire extinguisher, emergency lights, emergency generator, med gas testing etc. We currently have years and years of documentation being stored. Can these be disposed of or do we need to keep it because we need to keep records of all devices? I hope I’m explaining myself well.

A: I fully understand what you’re saying and you explained yourself well. Your questions is, can you dispose of testing/inspection documents older than 3 years? Well…. I guess you could, but I certainly would not recommend it.

A couple of years ago, during a Joint Commission survey, a surveyor asked a client of mine to produce a document to ensure a particular item was replaced and retested from seven (7) years prior. Fortunately, the client was able to produce that document, but it surprised the client (and me) that a surveyor would want to look at a document that was seven years old.

I understand that Joint Commission surveyors can and often do ask for documentation that goes back 3 years, so obviously having 3-years’ worth of documentation available is a necessity. But there are other reasons to maintain testing/inspection document, such as evidence for litigation cases. While one hopes they never have to utilize documents for that reason, it is a real possibility.

When I was Safety officer at the hospital where I worked, I found strategic storage areas where I kept my old testing/inspection documents. But if you’re asking if there are NFPA codes or standards, or Joint Commission standards that require maintaining these documents for any particular length of time, I would say no… I’m not aware of that.

Next Page »