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Healthcare life safety glossary

Annual fire-door assembly inspection

A source-linked healthcare life safety definition with related concepts, official authority references, and practical guidance pathways.

View this term in the complete glossary index

Definition

Annual fire-door assembly inspection definition

The annual inspection and testing process CMS identifies for fire door assemblies in health care occupancies under the 2012 Life Safety Code and 2010 NFPA 80. It should not be automatically applied to every non-rated corridor or smoke-barrier door.

Related healthcare life safety terms

Use these connected definitions to follow the code, facility, documentation, and survey relationships surrounding this term.

Fire door assemblyNFPA 80K211 — Means of Egress, General

Authority context

Official sources for Annual fire-door assembly inspection

CMS: S&C 17-38-LSC — Fire and Smoke Door Annual Testing RequirementsCMS states that fire door assemblies in health care occupancies are inspected and tested annually to 2010 NFPA 80; non-rated corridor and smoke-barrier doors are not subject to that same annual NFPA 80/105 requirement but remain part of routine maintenance.2012 NFPA 101 §8.3.3.1; 2010 NFPA 80 §5.2; CMS K211NFPA: NFPA 80: Standard for Fire Doors and Other Opening ProtectivesThe 2010 edition is the edition identified by CMS for annual fire-door assembly inspection in health care occupancies under the 2012 Life Safety Code.2010 NFPA 80 §5.2 (inspection, testing, and maintenance)NFPA: NFPA 101: Life Safety Code2012 edition is incorporated by CMS for covered providers, subject to regulatory exceptions.2012 NFPA 101 Chapters 18 and 19 (new and existing health care occupancies); Chapter 7 (means of egress); Chapter 8 (features of fire protection)The Joint Commission: Fire Protection — EC.02.03.05Public Joint Commission page identifying fire-protection topics, including annual fire-door testing.EC.02.03.05; EP 25 — annual fire door testing; CMS crosswalk: 42 CFR §482.41(b)(1)(i), A-0710

Practical application

Related Life Safety Express guidance

Article: Building a Survey-Ready Life Safety Binder: Essential Tabs and Required LogsArticle: Top 10 Most Common CMS Life Safety K-Tags in Healthcare (and How to Avoid Them)Article: NFPA 80 Annual Fire Door Inspection Checklist for Healthcare FacilitiesArticle: Understanding Fire Door Frame & Clearance Tolerances: Top Causes of Failed InspectionsArticle: Fire Door Labeling Requirements: Restoring Missing, Painted-Over, or Obscured Labels