By Marty Piepoli, Senior Consultant
Finally an answer... CMS agrees to adopt the 6 year interval for the testing of fire and smoke dampers... Read more!
You may recall in 2007 that The Joint Commission (TJC) adopted changes made by relevant NFPA codes permitting a six-year testing frequency for fire and smoke dampers in hospitals. The Joint Commission recognized these new requirements as an enhancement to the overall safety of our healthcare environment. Compliance with the six-year testing frequency (NFPA 80 and NFPA 105, 2007 edition) would allow a reduction in necessary shut-downs of hospital ventilation systems as well as the number of times dampers in patient-occupied environments needed to be accessed. The adoption of the new requirements suggested potential cost savings related to testing frequency.
Though the Centers for Medicare and Medicaid Services (CMS) did recognize the positive impact of the new testing requirements, it did not formally adopt the six-year time-frame, maintaining the four-year testing requirement in 2007. Hospitals were then expected to request a waiver from CMS to adopt the six-year testing cycle, with the waivers being valid for the duration placed on them by the CMS Regional Offices. Since that time, the American Society for Healthcare Engineering (ASHE) continued to have dialogue with CMS, in addition the ongoing communication between CMS and TJC related to deemed status, related to adopting the six-year frequency. Many organizations were frustrated with the 4-6 year window of testing frequency, attempting to make sure of compliance to satisfy both sets of requirements. Several organizations were caught in the process of requesting a waiver from the CMS Regional Office prior to a State survey or being cited for a deficiency in the testing frequency and then requesting a waiver.
On October 30, 2009, the CMS Survey and Certification Group issued a memorandum, S & C-10-04-LSC, permitting hospitals to apply the 6-year testing interval for fire and smoke dampers in hospital heating and ventilating systems, so long as the hospital’s testing system conforms to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105. The S&C memorandum references the impact on lowering the incidence of infections through the ventilation system and potential cost savings to organizations for the longer testing interval. As organizations review their current dates of damper testing, they should review the organization of the testing results. Consider the identification, location, building, wall, floor, etc. in order to manage the testing process and to address identified deficiencies quickly, especially if ILSM’s need to be considered. For the full text of the memorandum, click here.