Understanding new CMS requirements for inspecting doors


Subject Matter: Article | Topics: Codes and standards

By Chad Beebe, AIA, FASHE, ASHE deputy executive director

The new Conditions of Participation from the Centers for Medicare & Medicaid Services (CMS) include a requirement that has spurred questions. The CoPs reference NFPA 101 and NFPA 80 requirements that require routine inspections of fire doors by “qualified persons.” Several members have asked how whether they need to go to a class or earn a certificate to prove they are qualified. The answer is no. Someone who works in a hospitals and is familiar with the doors and the code requirements is qualified. The code states that a qualified person is someone “who, by possession of a recognized degree, certificate, professional standing, or skill, and who, by knowledge training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.” Employees can be qualified by attending training through an official program or through on-the-job training. The key is that the person should have “professional standing” or “skill” and either training or experience to handle door inspections. The code does NOT state that qualified persons must have third party training. It is up to the facility to decide what level of training a person needs to inspect the doors in the hospital.

Although a formal training program is not required, ASHE is working on several tools and resources related to fire doors to help keep facility departments up to speed on these requirements. Watch future editions of the ASHE Insider for information as tools are released.