Compliance News: CMS Categorical Waiver for Damper Testing Cycle

By Dean Samet, CHSP

On October 30, 2009, the Centers for Medicare & Medicaid Services (CMS) issued a “categorical waiver” whereby hospitals may apply the 2007 NFPA 80 and NFPA 105 six-year testing interval for fire and smoke dampers in heating and ventilating systems in hospitals without special application to CMS. This action brings CMS in line with The Joint Commission and other state agencies and authorities having jurisdiction (AHJs) across the country.

The CMS Survey and Certification Group October 30, 2009 memorandum states: “After due consideration of State survey agency findings and conclusions of the National Fire Protection Association (NFPA), we are issuing a categorical waiver pursuant to 42 CFR 482.41(b)(2) to permit a testing interval of six years rather than four years for the maintenance testing of fire and smoke dampers in hospital heating and ventilating systems, so long as the hospital’s testing system conforms to the requirements under 2007 edition of NFPA 80: Standard for Fire Doors and Other Opening Protectives and the 2007 edition of NFPA 105: Standard for the Installation of Smoke Door Assemblies. The six-year testing interval shall commence on the date of the last documented damper test.

“While the 1999 edition of NFPA 80: Standard for the Installation of Air-Conditioning and Ventilating Systems specified a four-year testing cycle, the NFPA more recently determined that an increase to a six-year interval did not lower the fire protection of hospitals but could instead lower the incidence of infections that may be spread when the ventilation system was shut down and restarted at shorter time intervals. There is also some indication of cost savings to institutions when maintaining these dampers on a longer time interval.

“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. At the time of a CMS onsite life-safety code survey, the hospital must notify the survey team that it has elected to operate under this categorical waiver and is in conformance with the testing requirements of the above-cited 2007 NFPA edition. The survey team will note this attestation in its records and apply the 2007 testing cycle requirements in the course of its survey.”