Smoke Control Testing Enforced by TJC

Starting with the 2022 Edition, and carried forward into the 2023 Joint Commission Standards, the retesting of smoke control systems in existing accredited hospitals has become mandatory. These life safety systems activate automatically via an initiating device like a smoke detector or sprinkler water flow switch, triggering HVAC equipment to manage smoke spread during a fire event. Hospitals might possess various smoke control systems, such as stair pressurization systems, elevator shaft pressurization systems, and floor-to-floor smoke control systems, based on their classification as a high rise building, having unenclosed vertical openings (i.e Atriums) or other legacy code requirements. It’s important to distinguish that post-fire smoke removal systems and HVAC systems in anesthetizing locations for vapor control are not categorized as active smoke control systems.

These requirements, set forth by the Joint Commission, are included in their Environment of Care Chapter, under EC.02.05.01, EP 27, and aligned with NFPA 101 18/ (2012 Ed). The mandated periodic testing of engineered smoke control systems aligns with engineering principles as detailed in NFPA 92 Standard for Smoke Control Systems (2012 Ed.). The standard outlines testing intervals and key elements of the testing process but does not stipulate acceptance criteria or operation sequence, which should be based on the original design and applicable codes.

Significantly, the Joint Commission Standards’ inclusion enhances enforcement of regular testing for these essential yet often neglected systems. In the past, smoke control systems were seldom tested as required, due to concerns about operational impact, such as affecting infection control.  Any existing smoke control systems that don’t meet NFPA 101 Life Safety Code (2012 ed.) Section performance requirements may continue operating, but only with the explicit approval of the authority having jurisdiction (AHJs), such as the local building or fire official. While accrediting agencies such as the Joint Commission and the Center for Medicare and Medicaid Services (CMS) are AHJs, it is unlikely that they would grant such exemptions.

See our previous blog on the details of smoke control retesting in accordance with the Requirements of NFPA 92 Here

Application of any information provided, for any use, is at the reader’s risk and without liability to Code Red Consultants. Code Red Consultants does not warrant the accuracy of any information contained in this blog as applicable codes and standards change over time. The application, enforcement and interpretation of codes and standards may vary between Authorities Having Jurisdiction and for this reason, registered design professionals should be consulted to determine the appropriate application of codes and standards to a specific scope of work.