New development: CMS now allows six-year damper testing in hospitals

The Centers for Medicare & Medicaid Services (CMS) issued a memo to its state survey agencies that now formally allows hospitals to use six-year testing frequencies for fire and smoke dampers.

What’s that mean for hospitals? A savings in time and money because crews will be able to see a one-third reduction for many damper testing efforts.

This move ends a conflicting provision between CMS and The Joint Commission, as the commission has allowed six year testing for some time under its environment of care standards, while CMS had maintained four-year testing rules.

The CMS memo is another notch in the belt for the American Society for Healthcare Engineering (ASHE), though it didn’t come without some headaches.

Just over the summer, ASHE announced that CMS would recognize the six-year frequency, only to find out CMS wasn’t quite on board with this idea. At the heart of the debate was whether CMS could issue waivers to hospitals to use the six-year testing, which ended up as a hurdle because CMS had no mechanism to issue a waiver until an inspector issued a citation for a violation.

But now CMS says that hospitals can immediately use a “categorical waiver” for the six-year frequencies. A hospital’s damper testing must conform to the requirements of NFPA 80, Fire Doors and Other Opening Protectives (2007 edition), and NFPA 105, Installation of Smoke Door Assemblies (2007 edition).

“Under this categorical waiver, a hospital that conforms to the above requirements will not need to apply in advance for a waiver nor will it need to wait until being cited for a deficiency in order to apply for a waiver,” CMS says in the memo.

The six-year testing interval begins on the date of the last documented damper test, CMS says.

Watch for more details in Healthcare Life Safety Compliance, the only monthly publication dedicated exclusively to covering fire protection requirements in hospitals.