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Are Your Fire and Smoke Doors Ready for CMS Inspection?
The U.S. Centers for Medicare & Medicaid Services require health care facilities to comply with new annual testing for their fire and smoke doors.
what you need to know
Federal and Local Compliance
A single health care facility has two sets of rules with which to comply—federal (CMS standards) and local (municipal codes). Defer to the highest fire safety standard among federal, local, and multiple municipalities.
Reporting
The facility now has to conduct a formal 11- or 13-point visual and operational test verifying that each door adheres to the NFPA 80 fire code including:
No open holes or breaks present on surfaceIntact glazing in placeDoors, frame, and hardware secured and in working orderThe new rule requires that the gaps around a swinging door in a closed position be a maximum of 3/4 of an inch at bottom and 1/16-3/16 of an inch between the door and frame.
What can you do?
each facility mustdocument the following:
Inventory of doorsLocation of doorsInspection record for each doorRepair record for each doorRe-inspection recordsBarrier Compliance Services and Grainger can help make sure your facility is compliant. Read the full article to learn more.
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what you need to know
ALL DAMPERS ARE AFFECTED
These include the following:
CURTAIN DAMPER
Oldest and lowest failure rateOnly used as fire damperNo smoke control
PNEUMATIC DAMPER
Air hoses hold damper in open positionPower or airflow to the attached actuators needs to be curtailed to assess closure efficacyFailed state is usually a closed damper
ELECTRIC DAMPER
Newest and most frequently usedHigh failure rate of 25-50 percentFailed state is usually a closed damperWhat can you do?
Increase inspection frequency from every 6 years to 2-3 year
Outsource maintenance and inspection to experts like Barrier Compliance Services and Grainger
Barrier Compliance Services and Grainger can help make sure your facility is compliant. Read the full article to learn more.
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Is Your Above Ceiling SpaceProperly Protected?
what you need to know
REASONS HOSPITALS AREN’T COMPLIANT INCLUDE:
Following International Building Code instead of CMS compliancePoor oversight of constructionPace of new technology creating issues during new equipment installationNew firestopping requirements
What can you do?
Best practices facilities can adopt include:
Involve leadership, facility maintenancestaff, and safety personnel frombeginning to end of constructionCommission fire and smoke rated barriersReview policies and proceduresto build in accountabilityHire specialized contractorsBarrier Compliance Services and Grainger can help make sure your facility is compliant. Read the full article to learn more.
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Is Your SprinklerSystem Compliant?
The number of fire sprinkler piping and support system violations have significantly increased for healthcare institutions.
what you need to know
When sprinkler piping supports structures other than the sprinkler system, this is a violation of CMS rules and standards. An accreditation agency will write up a Requirement for Improvement (RFI) mandating correction of the issue within 60 days.
Data cables contacting sprinkler lines comprise nearly 2/3 of allsprinkler line load deficiencies.
What can you do?
Best practices facilities can adopt include:
Create formal policiesfor ongoing monitoring
Build pathways for cabling
Plan for future cables, wires and tubes
Hire a third-partymanagement organization
Barrier Compliance Services and Grainger can help make sure your facility is compliant. Read the full article to learn more.
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Smoke and Fire Door Inspections
Are Your Fire and Smoke Doors Ready for CMS Inspection?
The U.S. Centers for Medicare & Medicaid Services require health care facilities to comply with new annual testing for their fire and smoke doors.
what you need to know
Federal and Local Compliance
A single health care facility has two sets of rules with which to comply—federal (CMS standards) and local (municipal codes). Defer to the highest fire safety standard among federal, local, and multiple municipalities.
Reporting
The facility now has to conduct a formal 11- or 13-point visual and operational test verifying that each door adheres to the NFPA 80 fire code including:
No open holes or breaks present on surface
Intact glazing in place
Doors, frame, and hardware secured and in working order
The new rule requires that the gaps around a swinging door in a closed position be a maximum of 3/4 of an inch at bottom and 1/16-3/16 of an inch between the door and frame.
What can you do?
each facility mustdocument the following:
Inventory of doors
Location of doors
Inspection record for each door
Repair record for each door
Re-inspection records
Barrier Compliance Services and Grainger can help make sure your facility is compliant. Read the full article to learn more.
concerns over Fire and Smoke Dampers
what you need to know
ALL DAMPERS ARE AFFECTED
These include the following:
CURTAIN DAMPER
Oldest and lowest failure rate
Only used as fire damper
No smoke control
PNEUMATIC DAMPER
Air hoses hold damper in open position
Power or airflow to the attached actuators needs to
be curtailed to assess closure efficacy
Failed state is usually a closed damper
ELECTRIC DAMPER
Newest and most frequently used
High failure rate of 25-50 percent
Failed state is usually a closed damper
What can you do?
Increase inspection frequency from every 6 years to 2-3 year
Outsource maintenance and inspection to experts like Barrier Compliance Services and Grainger
Barrier Compliance Services and Grainger can help make sure your facility is compliant. Read the full article to learn more.
above ceiling space protection
Is Your Above Ceiling SpaceProperly Protected?
what you need to know
REASONS HOSPITALS AREN’T COMPLIANT INCLUDE:
Following International Building Code instead of CMS compliance
Poor oversight of construction
Pace of new technology creating issues during new equipment
installation
New firestopping requirements
What can you do?
Best practices facilities can adopt include:
Involve leadership, facility maintenancestaff,
and safety personnel frombeginning to end of construction
Commission fire and smoke rated barriers
Review policies and proceduresto
build in accountability
Hire specialized contractors
Barrier Compliance Services and Grainger can help make sure your facility is compliant. Read the full article to learn more.
Hospital Sprinkler System Violations
Is Your SprinklerSystem Compliant?
The number of fire sprinkler piping and support system violations have significantly increased for healthcare institutions.
what you need to know
When sprinkler piping supports structures other than the sprinkler system, this is a violation of CMS rules and standards. An accreditation agency will write up a Requirement for Improvement (RFI) mandating correction of the issue within 60 days.
Data cables contacting sprinkler lines comprise nearly 2/3 of allsprinkler line load deficiencies.
What can you do?
Best practices facilities can adopt include:
Create formal policiesfor ongoing monitoring
Build pathways for cabling
Plan for future cables, wires and tubes
Hire a third-partymanagement organization
Barrier Compliance Services and Grainger can help make sure your facility is compliant. Read the full article to learn more.