What surveyors cite

• Doors that do not latch, or gaps over 1/8 inch

• Painted or missing labels

• Hold-open devices that do not release

• Open penetrations above the ceiling in smoke compartment walls

• Dampers that are overdue, inaccessible or never found

• Inspection records that do not list every door

On a CMS survey these findings land on Form CMS-2567 under a short list of tags: K211 for annual door testing, K363 for corridor doors, K372 and K374 for smoke barriers, and K521 for dampers. Our CMS K-tags guide explains what gets each one cited.

Built for your accreditor

• CMS enforces the 2012 Life Safety Code. Annual fire door testing has been required since 2018 (S&C 17-38).

• The Joint Commission moved hospital life safety into the new Physical Environment chapter in January 2026. Fire doors and barriers now score under PE.03.01.01. Our reports use both the new and the old numbers so your team can cross-walk.

• DNV surveys to the same Life Safety Code. Our reports map each finding to its K-tag.

The rules under the new numbers did not change. Our guide to Joint Commission fire door requirements in 2026 covers what moved and what surveyors still look for.

How we work in a hospital

• Techs who follow your ICRA permits and containment rules

• Night and weekend work on patient floors

• Interim life safety measures flagged when a barrier stays open overnight

• Damper testing on the 6-year hospital cycle, split across years if you choose

• Reports formatted for your Statement of Conditions and eSOC

What your report gives you

Your report opens with one page: openings inspected, pass rate by building and floor, failures by type and total repair cost. Then it goes opening by opening, with ID, location, rating, result, code reference and a photo of every failure. Each door and damper is marked on your life safety drawings, and every repair has an after photo and a re-test result. Your facilities team and your surveyor read the same document. See a sample fire door inspection report.

Services hospitals use most

• Annual fire door inspection of every rated door, with same-visit fixes

• Fire and smoke damper testing, with every damper tagged and mapped

• Above-ceiling firestop surveys of smoke compartment walls, sealed with listed systems

The Survey-Ready Program puts all three on one yearly schedule. Already cited? Priority Repair for survey citations walks your findings within 2 business days and gives you a dated plan to attach to your plan of correction.

Send a door count, floor plans or your last report to get a hospital fire door inspection quote.