Q: Do doors in smoke barriers in healthcare occupancies have to be tested and inspected? Section 188.8.131.52.2 of the 2012 Life Safety Code says smoke door assemblies have to be inspected and tested in accordance with NFPA 105.
A: Well, the answer is no… Smoke barrier doors that are non-rated are not required to be inspected annually in healthcare occupancies, even though 184.108.40.206.2 says they do. Here’s why:
Section 220.127.116.11 says doors in smoke barriers shall comply with 8.5.4 and all of the following: 1) Doors shall be self-closing; 2) Latching hardware is not required; and 3) The doors do not have to swing in direction of travel.
Section 18.104.22.168 says where required by chapters 11 through 43, doors in smoke barriers that are required to be smoke leakage-rated shall comply with section 22.214.171.124. [NOTE: Chapters 18 & 19 for healthcare occupancies do not require smoke leakage-rated doors in smoke barriers…. Therefore, compliance with section 126.96.36.199 is not required.]
Section 188.8.131.52(4) says where door assemblies are required elsewhere in the Code to be smoke leakage-rated, door assemblies shall be inspected in accordance with 184.108.40.206.
CONCLUSION: Since the healthcare occupancy chapters do not require smoke barrier doors to be smoke leakage-rated, then there is no requirement to be compliant with 220.127.116.11.2 that says the smoke doors need to be inspected.
Section 18.104.22.168 says where specific requirements contained in chapters 11 through 43 differ from general requirements contained in chapters 1 through 4 and from chapter 6 through 10, then the requirements of chapters 11 through 43 govern. Since the healthcare chapters do not require smoke barrier doors to be smoke leakage-rated, then it conflicts with section 22.214.171.124.5.2, and when that happens, you follow the occupancy chapter requirements.
The problem is… not all authorities having jurisdictions (AHJs) know this or understand this. Case in point: CMS recently instructed their state agency Life Safety surveyors that all smoke doors in healthcare occupancies need to be tested and inspected, citing section 126.96.36.199.2.
In addition, CMS is also teaching their LS surveyors that doors in healthcare occupancies that meet the requirements of 188.8.131.52.1 have to be tested as well, which is not entirely true. These doors identified in 184.108.40.206.1 only have to be tested in assembly occupancies, educational occupancies, or residential board & care occupancies. The exception is, some hospitals have mixed occupancies that include the requirements for assembly occupancies, so in those cases, yes, the doors in 220.127.116.11.1 would have to be tested and inspected on an annual basis.
Since CMS and their state agencies are AHJs, you must follow their requirements, even if their requirements are not consistent with the NFPA codes and standards. Let’s just hope CMS finds the errors of their ways and rescinds their directive for all of the non-required testing and inspections.
Brad Keyes, CHSP, is the owner of KEYES Life Safety Compliance, and his expertise is in the management of the Life Safety Program, including the Environment of Care and Emergency Management programs.
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