Incorrect Interpretations on Smoke Door and Fire Door Testing
by Brad Keyes, CHSP, on Dec 9, 2016 12:00:00 AM
I just found out yesterday that CMS is teaching their state agency LS surveyors that smoke barrier doors need to be tested in healthcare occupancies. This interpretation of the 2012 Life Safety Code from CMS is incorrect, but your state agency on behalf of CMS may be expecting you to do this.
Yes… section 126.96.36.199.2 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 188.8.131.52 says when specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the occupancy chapter shall govern. Section 184.108.40.206 says doors in smoke barriers shall comply with section 8.5.4. Section 220.127.116.11 says where required by chapters 11 -43 doors in smoke barriers that are required to be smoke leakaged-rated, must comply with section 18.104.22.168 (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. You may show them this code trail and perhaps they will allow you to not test your smoke doors, but 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, CMS has instructed their state agency LS surveyors that healthcare occupancy doors in 22.214.171.124.1 must be tested, even if they are not fire-rated doors. This also is incorrect. The doors identified in 126.96.36.199.1 do not apply to healthcare occupancies so they are exempt from having to be tested. Only doors in assembly occupancies and residential board & care occupancies need to comply with 188.8.131.52.1.
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 184.108.40.206.1 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 220.127.116.11).