New CMS LSC Survey and Certification Letter - Permitted Gaps in Corridor Doors and Doors in Smoke Barriers

Attached is the link to a survey and certification issued by the Centers for Medicare and Medicaid Services (CMS) on 4/20/07: Multiple Providers - Hospitals, Ambulatory Surgical Centers, Nursing Homes, religious Non-Medical HealthCare Institutions, Programs of All-Inclusive Care for the Elderly (PACE) Facilities, Critical Access Hospitals, Intermediate Care Facilities for the Mentally Retarded - Permitted Gaps in Corridor Doors and Doors in Smoke Barriers.

http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter07-18.pdf

This is revision in interpretation will serve to reduce or prevent many door-related deficiency citations under the LSC survey, potentially saving millions of dollars overall in correction costs,

The memorandum clarifies requirements for door gaps in the 2000 edition of the Life Safety Code (LSC), National Fire Protection Association (NFPA) 101.
CMS cites the 36" - 44" wide, solid core wood doors currently found in the corridors of most health care facilities, stating that because these doors expand and contract in response to changes in temperature and humidity, it is not practical to maintain a minimum of a 1/8" gap.
This information applies to requirements in the LSC for corridor doors other than those in required enclosures of vertical openings, exits, and hazardous areas. It does not apply to doors in smoke barriers.
The LSC states that corridor doors should be relatively smoke tight, but does not specify a minimum gap for corridor doors, and specifically states that compliance with NFPA 80, Standard for Fire Doors and Fire Windows, is not required.
Due to the lack of specificity and subjective language in the Code, CMS has deemed the following guidance to be appropriate:

        +       In a smoke compartment that is not fully sprinklered, a gap between the face of a corridor door and the door stop should not exceed 1/4 inch, provided the door latch is functioning.
        +       In a smoke compartment that is fully sprinklered, a gap between the face of a corridor door and the
        door stop should not exceed 1/2 inch, provided the door latch is functioning.

CMS also clarifies that there is no criterion for a "light test" in the LSC and/or other NFPA Codes and Standards, i.e., deeming a gap too large and citing the facility if a surveyor sees light through the door gap. The so-called light test is not a valid method for determining acceptability of gaps in doors.
To enhance clarification, the memorandum include a Q and A and plan view drawing of a door and frame.
The memorandum reflects current policy and is effective immediately.