In Survey and Certification Letter No. S&C 17-38-LSC dated July 28, 2017, the Centers for Medicare & Medicaid Services (CMS) provided clarification regarding the requirement for annual inspection and testing of fire doors.

It also announced that it would extend the deadline for compliance with the requirements by six months from July 6, 2017 to January 1, 2018.

Key points covered in the letter include the following:

• In health care occupancies, fire door assemblies are required to be annually inspected and tested in accordance with the 2010 National Fire Protection Association (NFPA) 80.
• In health care occupancies, non-rated doors assemblies including corridor doors to patient care rooms and smoke barrier doors are not subject to the annual inspection and testing requirements of either NFPA 80 or NFPA 105.
• Non-rated doors should be routinely inspected as part of the facility maintenance program.
• Full compliance with the annual fire door assembly inspection and testing in accordance with 2010 NFPA 80 is required by January 1, 2018.
• Life Safety Code (LSC) deficiencies associated with the annual inspection and testing of fire doors should be cited under K211 – Means of Egress – General.