Fire Door Testing

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.


Life Safety Drawings

Q: Should the official Life Safety drawings for an existing space within a hospital show the rating on a fire barrier as it was originally built or as it is required to be rated according to the Life Safety Code? We have a soiled utility room that was required to be sprinklered and constructed with smoke resistant partitions according to the code in effect at the time it was constructed, but it was constructed to 1-hour fire resistance rated walls and a 45 minutes rated door. What should the Life Safety drawings reflect for the fire rating of the soiled utility room walls?

A: This may be a tricky question to answer. To be sure, Life Safety drawings are not construction drawings, so the actual type of construction for the barrier is not what is needed. The concept of Life Safety drawings is to indicate what fire-rating the Life Safety Code requires the barriers to be. This is not the same as saying the Life Safety drawings should reflect what fire rating the walls were constructed to. A case in point is in the lower level of a hospital, it is quite common for designers to specify cement block walls for the corridors since there is so much support services traffic in these areas. The walls where carts and pallets commonly travel will stand up to a lot more abuse than steel stud and gypsum board walls. But cement block walls often have a fire-rating of 2-hours or more, but that is not why cement block walls were chosen. The Life Safety Code may only require non-rated smoke resistant walls in the corridor, so that is what the Life Safety drawings should say; not the actual fire rating of 2-hour (or more). A surveyor will hold you accountable to what your Life Safety drawings say; so it is best to only identify what the Life Safety Code requires for the walls and barriers, rather than what they were actually constructed to. In the case of your soiled utility room that qualifies as existing conditions, I suggest the Life Safety drawings should reflect what is required for existing conditions.

Electric Blankets

Q: Are electric blankets permitted to be used by patients in long term care facilities? I cannot find any references to electric blankets in any NFPA codes or standard.

A: Technically, you are correct: There is no specific NFPA code or standard that prohibits the use of electric blankets in healthcare. However, there are significant risks to the patient and staff if you do use them, and before you allow the use of electric blankets, you need to conduct a risk assessment. At a minimum, the risk assessment needs to address to following issues:

  • Could the heat generated from the blanket cause epidermal damage to the patient?
  • Could the electrical portion of the blanket become damaged due to abuse or spillage, and cause harm to the patient?
  • Could the electrical cord become damaged (frayed) by other wheeled equipment rolling on top of the cord?
  • Could the electrical cord become a tripping hazard to the patient or staff?
  • Could the patient accidentally set the temperature control too high and cause damage to their body?
  • How will the electric blankets be maintained and inspected, and who will perform this task?

Another issue that you need to address… Why do you want to use electric blankets? Is the patient room too cool for the patient’s comfort level? There are minimum temperature levels that the organization must meet. If a surveyor observes the use of electric blankets, they have the right to investigate to determine if you did a risk assessment that addresses all of the above issues, and more. They have the right to review your risk assessment and they have the right to disagree with the conclusions in the risk assessment. In other words, no matter how you justify their use, a surveyor can still cite you for an unsafe environment for using electric blankets if they want. My advice: Stay away from electric blankets, and do not allow them. They become more problems than they are worth. Check with your state and local authorities to determine if they have regulations that would prohibit their use.

NFPA 110

Q: Which edition of NFPA 110 are we expected to follow? I read that we’re expected to comply with the 1999 edition, the 2005 edition and now the 2010 edition. Which is correct?

A: The 2000 Life Safety Code references the 1999 edition of NFPA 110. The 1999 edition of NFPA 99 also references the 1999 edition of NFPA 110. Since CMS is still on the 2000 LSC, then the 1999 edition of NFPA 110 governs. However, Joint Commission standards references the 2005 edition of NFPA 110 for the 3-year, 4-hour load test, because this load test is not required in the 1999 edition of NFPA 110. Apparently, the accreditor feels the 3-year, 4-hour load test has value and wants their clients to comply with the load test. Joint Commission can do this since the addition of the 3-year, 4-hour load test is not in difference to the 1999 edition of NFPA 110; it is just an addition, so CMS allows it. HFAP and DNV have written similar standards that reference the 3-year, 4-hour load test found in the 2005 edition of NFPA 110.

But last year, CMS issued categorical waivers in their S&C memo 13-58 that will permit hospitals, critical access hospitals, long-term care facilities, ambulatory surgical centers, and inpatient hospices to use the provisions found in the 2010 edition of NFPA 110 immediately without waiting for the new LSC to be adopted. The 2010 edition of NFPA 110 will allow you to reduce the annual load test from 2-hours down to 90-minutes when the monthly load tests do not meet the 30% load capacity of the nameplate value. All of the accreditation organizations recognize and support this CMS position, but be aware that some state agencies do not.

The 2010 edition of the NFPA 110 is referenced by the 2012 edition of the Life Safety Code and will become the rule once the 2012 LSC is adopted. So, for the most part, the 1999 edition of NFPA 110 is the one to use, unless you’re Joint Commission or HFAP accredited, then you must also follow the 2005 edition of NFPA 110 for the 3-year, 4-hour load test. Also, you have the option to use the 2010 edition of NFPA 110 for the annual load test through the use of the CMS categorical waivers. Sounds confusing, but everyone will be on the 2010 edition of NFPA 110 once CMS adopts the 2012 edition of the LSC.

To download your own copy of the CMS S&C memos, go to:

The New 2012 Life Safety Code

Q: When will we know if CMS will adopt the 2012 version of the NFPA LSC book?

A: You will not have to worry about that… Nearly everyone will be writing about it and there will be public announcements made in every industry newsletter and blog across the country. First, CMS will publish an announcement of the rule change to adopt the 2012 LSC in the Federal Register; then membership organizations like ASHE will alert their members of the news; then accreditation organizations like Joint Commission will issue statements and press releases about the adoption; then industry newsletters and blogs (like this one) will be talking about it. It will not go un-noticed. The good news is CMS has already said in the 2013 spring Unified Agenda that they intend to propose a rule that will require compliance with the 2012 edition of the LSC; the bad news is we don’t know when they will issue the final rule. I suspect it will be at least another 6 – 12 months if not longer as CMS must first publish a proposed rule change in the Federal Register, then allow 60 days for public comment; then take the time to review and respond to all the public comments; then they will issue the final rule change to adopt the 2012 LSC, again in the Federal Register. The length of time between CMS reviewing the public comments and issuing a final rule could be 12 months or longer (based on the last time they adopted a newer edition of the LSC). I don’t expect the effective date for the adoption of the 2012 LSC to be until early 2015. The misconception that seems to be very common is the myth that Congress needs to approve the rule change to adopt the 2012 LSC, which is not true. Congress has 60 days to review the final rule and if they don’t like it, they can only challenge it through the federal court system. This is all based on the Administrative Procedure Act of 1946 that limits how federal agencies make changes to their rules. There have even been comments by industry experts that CMS should change the rule, to allow them to adopt a newer edition of the LSC without having to go through the due diligence process of proposed rules and public comments. That does not seem to be a good decision for the public, as then there would be no process for us to make comments on a proposed change to a newer edition of the LSC. All in all, the way they are doing it now is a good system. Not very fast, but what part of government is?

Waiting Areas

Q: Our Risk Management Department has conducted an assessment of our waiting areas in our hospital.  They are stating that staff should be able to see all patrons who are waiting in lobbies and corridors.  If they cannot, then mirrors or cameras should be installed allowing staff to monitor their behavior.  I’m guessing their concern is for an individual passing out in the waiting area. Is there a code requirement for staff observation or cameras?

A: It depends on the circumstances. Waiting areas that are open to the exit access corridor are required to meet criteria found under section in the 2000 edition of the Life Safety Code (LSC). This criteria includes, among other things, either direct supervision by a staff member or smoke detection in the open areas. Depending on the Accreditation Organization (AO) that you have, and your local and state authorities, direct supervision may be interpreted to mean staff in attendance to observe the waiting area, or a closed circuit television system which is monitored by another individual. The code at this point does not say ‘constant supervision’ which implies the supervision by the staff must remain constant. Direct supervision implies observation of the open areas is not constant. As far as meeting the code requirements, it seems to me that the addition of smoke detectors would far outweigh the cost of having staff observing the open areas. As always, please check with your local or state authorities to see if they have other requirements.

Approval to Remove non-Required Systems

Q:  Our existing hospital has an old smoke control system [not associated with an atrium] that was originally designed to remove smoke from the hospital. This system was code compliant some years ago but this requirement was later [circa 1980] removed from the local building code.  The smoke removal fan system was later abandoned and is no longer used as designed. The abandoned smoke control fan system is only within a small portion of the existing hospital. The hospital is considering removing it so it does not need to continue to maintain it.

A set of drawings would be produced and we would obtain the local building department approval prior to removal of the smoke control fan system.  What other approvals should I obtain before proceeding with the removal of this system?

A: Chapter 18 (for new occupancy) of NFPA 101-2000 does not require engineered smoke control systems, and section 4.6.7 of the LSC does not require you to maintain a system that is not required by the new occupancy chapter. However, most state licensing regulations have additional requirements that are not part of the LSC, and you should check with your state authorities to see if they have a concern with this action. Check with your property insurance company as they may count of the engineering smoke control system in the calculation of your premium rate. You should also review all the equivalencies or variances granted by your AHJ, looking to see if the smoke control system was identified in their acceptance. If so, then you can not remove the smoke control system without re-addressing the issues identified in the equivalencies or variances.

Different Editions of the Life Safety Code

Q: How do I know which edition of the NFPA 101 Life Safety Code I should be following? I see you refer to the 2000 edition many times, but shouldn’t I follow the most recent edition?

A: In March, 2003, the Centers for Medicare and Medicaid Services (CMS) adopted the 2000 edition of the LSC, which was a significant improvement as previously they were still recognizing the 1985 edition. Subsequently, other accreditation organizations with deeming authority, such as The Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP) and Det Norske Veritas Healthcare Inc. (DNV) have also adopted the 2000 edition and have stated they will wait until CMS adopts a more recent edition before they do so as well. CMS has indicated that they may adopt a more recent edition of the LSC as early as the year 2012.

There are other organizations that have adopted more recent editions of the LSC, such as the Veterans Administration (VA) and various state and local governments. Depending on your location and who your Authorities Having Jurisdiction (AHJ) are, you may have to comply with a more recent edition. If that is the case, you may petition The Joint Commission and CMS for permission to comply with a newer version.