CMS released a Q&A on fire door requirements.
Q: S&C Letter 17-38-LSC lays out the requirements for Fire & Smoke Door Annual Testing Requirements. In the letter it states, “Non-rated doors, 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.”
My question is: If a facility has 20 minute labeled doors to resident rooms (from 25 years ago) and they are no longer required to be rated, do they need to follow NFPA 80 for testing and inspection requirements just because they are labeled? That wouldn’t make much sense to me, but I wanted to check to see how CMS is enforcing this. It’s also my understanding that they can remove the labels from the doors if not required to be rated any longer.
A: They do not have to do those doors. And I would not recommend taking off the labels. In some situations they may have been there for another reason. Some were put in as the doors cost the same as a regular door, but in some cases the smoke and/or fire barriers jig and jog along those corridor walls. If they remove the labels, then they need them back, they will have to have a company back out to recertify the doors and re-placard them.
