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 220.127.116.11.2 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 18.104.22.168 says when specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the occupancy chapter shall govern. Section 22.214.171.124 says doors in smoke barriers shall comply with section 8.5.4. Section 126.96.36.199 says where required by chapters 11 – 43 doors in smoke barriers that are required to be smoke leakaged-rated, must comply with section 188.8.131.52 (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 184.108.40.206.1 must be tested, even if they are not fire-rated doors. This also is incorrect. The doors identified in 220.127.116.11.1 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 18.104.22.168.1.
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 22.214.171.124.1 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 126.96.36.199).
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.