Fire/Smoke Damper Drawings

Q: A California Life Safety Code surveyor enforcing the 2012 edition of the LSC asked for a map of all of the smoke and fire dampers in the building (skilled nursing home) and threatened a deficiency if one could not be produced. I have been searching for the 2012 LSC and cannot find any such reference to this specific requirement. I have not heard of this before. Can you shed any light on this matter?

A: Yes, I can understand the surveyor’s request, although threatening you with a citation seems a bit much.

The surveyor’s position is: How can you effectively maintain all of your fire/smoke dampers if you do not know where they are located? Having them documented on a drawing is logical in that you can then properly maintain the dampers. Without having them documented on a drawing, the chance is great that you would miss one or more dampers and they would not be tested.

But, to be sure, there is no standard that requires you to have drawings showing the locations of all fire/smoke dampers. But if you provide a test report that says you tested 25 dampers, how do you know where these 25 dampers are located, and you don’t have more than 25, and you got them all tested? I can see the surveyor could cite you with a finding that would read something like this: “The organization failed to provide evidence that all fire and smoke dampers were properly tested.”

But I don’t approve of surveyors making threats… that is just unprofessional.

Fire Damper Removal

Q: I have a building that is fully sprinklered and has full protection from the fire alarm system, with multiple floors. The age of the building is 40+ years and when it was constructed it was not fully sprinklered and had fire and smoke dampers (some still pneumatic) to control the spread of fire and smoke. Our last damper inspection revealed that we have 44 dampers that are not functioning or they are inaccessible to inspect. My question is, since we are now fully protected by sprinklers and are using the rule for smoke compartments on the floors, are all the dampers we have are necessary or can we possible take some out of service? What is the rule on this situation?

A: That’s tough question to answer without actually seeing the facility, but I’ll take a stab at it: If the smoke compartment layout has been re-designed, and you find that some existing smoke barriers are no longer required, then the smoke dampers located in those smoke barriers could be removed, pending approval from your state and local authorities on hospital construction. However, if existing smoke barriers remain in use but you would like to remove the smoke dampers because section (2) of the 2012 LSC says smoke dampers are not required in new construction smoke barrier where the HVAC duct is fully ducted and the adjoining zones are fully sprinklered…. That may not happen because the IBC codes do not allow this. If you are required to comply with the IBC codes, then this will be a problem. Check with your state and local authorities to see if they require compliance with the IBC codes.

Fire Damper Testing Frequency for LTC Facilities

Q: I work in a long-term care facility. It used to be that fire dampers had to be tested/inspected every four years, but I’ve heard that has changed with the new 2012 LSC. Now fire dampers are only required to be tested/inspected once every 6 years. I am perplexed because I cannot seem to locate where in the LSC it is written. Can you please tell me where it is written that we can now test fire dampers once every 6 years?

A: You seem to have it backwards. Section of the 2012 Life Safety Code requires compliance with NFPA 80 for all openings (i.e. doors, ductwork, windows, etc.) in fire-rated barriers. Section of NFPA 80-2010 says fire dampers in hospitals are required to be tested and inspected every 6 years; for all other facilities the test and inspection frequency is every 4 years.

Since Long-Term Care facilities are not hospitals, you would be required to test and inspect your fire dampers once every 4 years. The same holds true for smoke dampers.

Inaccessible Fire Dampers

Many of you may be familiar with the Joint Commission’s standard practice for inaccessible fire dampers: If the fire damper is inaccessible during the required testing period, the hospital can choose to insert the damper into the Statement of Conditions Plan for Improvement (PFI) list with a 6-year projected completion date. Then the hospital does not have to resolve the inaccessible fire damper, and they will not be cited for not performing the required testing.

Well, no other accreditation organization (AO) or state agency surveying on behalf of CMS has that luxury. CMS has been very clear to all AOs: If you observe a deficiency, then you must cite it. AOs and state agency surveyors are not permitted to not cite a deficiency if they are presented evidence that a feature of the Life Safety Code is non-compliant. And an inaccessible fire damper on a PFI list is clear evidence that it has not been tested.

So, why does Joint Commission continue to allow their hospital clients to not test inaccessible fire dampers and permit them to place them on the PFI list if CMS does not allow this practice? It is my observation that the reason is mainly due to the fact Joint Commission has been operating as an independent authority since 1965 without having to meet CMS’s rules and regulations, until just recently (2009).

For the record, I like the Joint Commission PFI list and think it is a very good deal for hospitals. It provides the hospital an incentive to get out and find their deficiencies before a survey and manage a solution to them through the PFI list. Then a TJC surveyor will not cite them for the deficiency. It’s a win-win situation. Hospitals are motivated to conduct self-examinations of their facilities and find all the LSC deficiencies they can, which results in a safer environment for their patients. I wish all AOs and state agencies had that option. However, CMS is threatening to remove the feature from Joint Commission and if they succeed, then the fear is hospitals will not be pro-active and look for their own deficiencies, and sit back and wait to see if the surveyors will find them during the triennial survey.

Even if Joint Commission allows you to manage the inaccessible fire damper through the PFI list, that’s only good for a Joint Commission survey. You still need to make the damper accessible and then test it for all the other AHJs.

So, when a fire damper cannot be tested because it is inaccessible… you have little choice but to make the fire damper accessible and then test it. There is another option though; you may request a waiver during the Plan of Correction process, provided it is a significant hardship to the hospital. Waivers are much more difficult to get approved lately through CMS but it is the only other option to you.

PFIs on Inaccessible Fire Dampers


There seems to be much discussion lately on how to manage the Joint Commission Statement of Conditions Plans For Improvement (PFI) on inaccessible dampers. Joint Commission has instructed healthcare organizations to write a PFI for inaccessible fire or smoke dampers, and place a projected completion date of 6 years on them.

I have been telling my clients to close the PFI out at the end of the 6-year cycle; examine the fire dampers again to see if anything has changed that now allows them to be accessible (and then test them); and if they are still inaccessible, write up a new PFI with a new 6-year projected completion date. I vaguely remember that Joint Commission initially wanted hospital to request another 6-year extension on PFIs for inaccessible fire dampers, but I think they soon realized their error as they would be over-whelmed with extension requests. Also, they typically only allow one extension per PFI, so after the first 12 years, would they grant another extension? I also remember them saying to just close out the PFI and write a new one.

I don’t have a copy of the 2007 EOC article on the PFIs for inaccessible fire dampers, but 7-year old information seems a bit old for me to trust. People and organizations change their mind in 7-years. If anyone has any doubt, they should contact the Standards Interpretation Group at Joint Commission directly and ask them. Their number is (630) 792-5900, select option 6.


Radiant Ceiling Fire Dampers

I recently received a message from an old friend in regards to the testing requirements for ceiling mounted fire dampers. It was his contention that the ceiling was just a simple acoustical tile and grid suspended ceiling and by itself was not 2-hour fire rated and therefore the ceiling mounted fire dampers were not required, nor did they have to be tested.

What he actually had was radiant ceiling fire dampers mounted in the supply and return HVAC diffusers in the ceiling. These devices are part of an UL listed floor/ceiling assembly such as G-235 or G-227, which brought back lots of bad memories for me.

The hospital were I spent most of my development career years had an addition they wanted to have built in the early 1970’s, and the succesful contractor offered millions $$$ in savings to the hospital if they could install a UL listed (approved by building codes and state regulations) G-235 floor/ceiling assembly, rather than the heavy-duty poured concrete beams and floors and decks that were specified. The hospital leaders at the time could only see $$$ saved in construction costs, and approved the bid.

The floor/ceiling assembly consists of unprotected steel bar-joists supporting a poured light-weight concrete floor that is thinner and has less psi density than a regular 2-hour fire rated concrete floor. The UL standard G-235 makes up the fire rating by having a special suspended ceiling consisting of a particular acoustical tile and grid system, complete with radiant fire dampers mounted inside the HVAC supply and return (or exhaust) diffusers, and all openings in the ceiling grid (such as light fixtures, PA speakers, etc.) had to be tented with a special insulating materials that resembled mineral wool. And, all the lay-in ceiling tiles had to be clipped.

It wasn’t long after the addition was opened for business that the hospital maintenance staff was either poorly trained or poorly supervised, but within 15 years or so, many of the special requirements of UL G-235 (such as the radiant ceiling fire dampers, the tenting and the special ceiling tiles) were removed and replaced with hospital standard materials, that did not comply with the UL listing. And most of the tiles were never re-clipped after lifting them out of the grid. Enter the state survey agency for HCFA (that’s CMS before it was called CMS) and they found all of the problems that 15 years of neglect created. The hospital wanted to restore the ceiling to UL G-235 standards, but soon found that UL withdrew the listing on G-235 and the state survey agency made the hospital adhere to UL G-227 which was similar, but more difficult.