Fire doors are a critical line of defense in healthcare facilities, protecting patients, staff, and valuable assets from the rapid spread of fire and smoke. The Centers for Medicare & Medicaid Services (CMS) mandates strict fire door inspection requirements as part of its broader life safety regulations for hospitals, clinics, and long-term care environments. Ignoring or overlooking these requirements can result in serious penalties, failed inspections, and, most importantly, jeopardized patient safety.
This guide covers what healthcare facility managers need to know about CMS fire door inspection requirements, common pitfalls, and how to streamline compliance—so you’re always ready for your next survey or audit.
CMS enforces the National Fire Protection Association (NFPA) 101 Life Safety Code, which sets the standard for fire door assemblies in healthcare settings. All healthcare facilities receiving Medicare or Medicaid funding must comply.
Key Requirements:
Healthcare facilities have unique risks due to constant foot traffic, equipment movement, and frequent renovations. Common fire door issues include:
Any of these deficiencies can result in non-compliance and may compromise patient safety during an emergency.
Before your next CMS survey, ensure the following:
Facility management is responsible for ensuring fire door inspections are performed on schedule, that records are current, and that corrective actions are tracked. Many facilities rely on certified third-party inspectors to provide the expertise and documentation needed for CMS compliance.
With decades of experience serving healthcare facilities, AAA Fire Protection provides:
Our team ensures you never miss an inspection deadline and that your facility passes CMS surveys with confidence.
1. Are CMS fire door inspections really required every year?
Yes. CMS mandates annual inspections for all fire door assemblies in healthcare facilities.
2. What happens if my facility fails a CMS fire door inspection?
You may face deficiencies, corrective action requirements, potential fines, and risk losing accreditation.
3. Can facility staff perform the inspections?
While staff can perform basic checks, CMS requires inspections to be conducted by “knowledgeable persons,” typically certified professionals.
4. What documentation is needed?
Maintain inspection reports, deficiency logs, repair records, and proof of corrective action for every fire door.
5. Who checks for compliance?
CMS surveyors and life safety inspectors will review documentation and may physically inspect fire doors during surveys.
We recommend scheduling an annual inspection at minimum. However, high-occupancy buildings or industries with stricter regulations may require quarterly or semi-annual inspections to stay compliant.
Yes. Every inspection includes detailed reports, code citations, and corrective recommendations — all formatted for AHJs, insurance providers, and internal audits.
We offer multi-location service coordination, centralized scheduling, and standardized reporting to keep everything organized and consistent across your properties.
Absolutely. If we identify any violations, our team provides clear next steps, correction plans, and priority timelines to get you back in compliance quickly.
Yes. All of our inspectors are certified, trained to current NFPA standards, and stay up to date with local, state, and federal fire codes.
Most inspections take between 1–3 hours depending on the size and complexity of your facility. Larger or multi-building sites may require more time or follow-up.
