Author(s): Kristin Bigda. Published on January 4, 2016.

Our Doors, Ourselves

Why healthcare facilities need to bone up on their fire-protection rated doors. BY KRISTIN BIGDA

HEALTHCARE FACILITIES have a lot of doors. Many doors, such as those protecting exit stairs, horizontal exits, and hazardous areas, are required to be fire-protection rated. With the anticipated adoption of the 2012 edition of NFPA 101®, Life Safety Code®, by The Centers for Medicare and Medicaid Services (CMS), many healthcare facilities will have to add fire-protection rated doors to their list of building systems that require periodic inspection and testing.

The 2000 edition of NFPA 101, which referenced the 1999 edition of NFPA 80—then known as Standard for Fire Doors and Fire Windows—included only minimal mention of fire door inspection. The 2012 edition of NFPA 101, by comparison, references the 2010 edition of NFPA 80, now known as Standard for Fire Doors and Other Opening Protectives, which requires that fire doors be inspected and tested on an annual basis. What was formerly a building component with marginal provisions for inspection, testing, and maintenance is now one that will require a formal inspection procedure and documentation.

The 2010 edition of NFPA 80 provides the required inspection frequency as well as a list of minimum items that must be verified during the annual inspection for swinging door assemblies and other types of fire door assemblies, such as rolling and sliding fire doors. In addition to the basics that are carried through from the 1999 edition, such as operability (swinging freely and latching positively), removal and replacement, and repairs, the annual inspection requirements will help ensure that doors, which are often exposed to heavy traffic and wear and tear in healthcare occupancies, are maintained in good working condition to function as intended in the event of a fire.

Education need

Fire doors are installed in walls and floors that have a fire resistance rating and are used to ensure the fire barrier provides continuous protection without any points of weakness or lesser protection. Fire barriers and fire doors subdivide areas of buildings into fire compartments to prevent the spread of fire and toxic gas throughout the building. Doors are ideal examples of the maxim “a chain is only as good as its weakest link”—leaving unprotected holes in these barriers can void the function and purpose of the rated assembly. Fire doors can, and often are, the weakest link if they are not installed properly, or if they are not inspected and maintained for the life of the assembly.

In 2007, NFPA 80 introduced a requirement to inspect and test fire door assemblies on an annual basis. This requirement brought to light the importance of fire doors and their role in protecting occupants and property from fire. In jurisdictions now adopting newer editions of model codes such as NFPA 1, Fire Code, and NFPA 101, the requirement for the annual inspection of fire doors follows. Even though the requirement first entered the standard nine years ago, the impact of fire door inspection requirements is just starting to hit most jurisdictions, and there is a critical need to educate owners, facilities managers, installers, inspectors, and code officials.

All requirements for the inspection, testing, and maintenance of fire doors assemblies are located in Chapter 5 of NFPA 80. According to the standard, visual inspections and operational tests—and the accompanying documentation of the inspections and tests—are required for fire door assemblies upon completion of installation, periodically (not less than annually), and upon completion of maintenance work.

As staff liaison to the NFPA Technical Committee on Fire Doors and Windows, responsible for the development and revision of NFPA 80 and NFPA 105, Smoke Door Assemblies and Other Opening Protectives, I am seeing a tremendous increase in the demand for knowledge and education on fire door assemblies and, in particular, inspection, testing, and maintenance procedures in healthcare facilities. Planning for these newly required inspections will require all parties to work together to ensure they are scheduled, completed, and reviewed, and that any cited deficiencies to the door assemblies be corrected in the appropriate time.

Responsibilities of fire door inspections fall to three groups of users: building owners/facilities managers, fire door inspectors, and authorities having jurisdiction (AHJs). Building owners/facilities managers are responsible for scheduling inspections, maintaining documentation, and being educated on changes to the standard and the need for building inspection, testing, and maintenance. Fire door inspectors are responsible for conducting the inspections, being properly educated on the knowledge and understanding of the operating components of the fire door assembly, and remaining up to date on the requirements in NFPA 80. (NFPA 80 requires that those conducting the inspection have adequate knowledge and understanding of the operating components of the type of door subject to testing. Inspectors can be in-house facility staff or a hired third party vendor. Demonstration of competency should be confirmed by the authority having jurisdiction.) AHJs/code officials are responsible for verifying that the inspections that have occurred, evaluating that the inspections follow the procedures set forth in NFPA 80, and verifying the credentials of those conducting the inspections.

Now is the time for healthcare facilities to become educated on the new requirements for fire door assemblies—when the time comes for the 2010 edition (or newer) of NFPA 80 to be fully enforced, plans will have been put in place to schedule inspections, train staff members, make updates to door assemblies, and seek out the necessary resources to assist with the inspections.

​KRISTIN BIGDA is staff liaison to the NFPA Technical Committee on Fire Doors and Windows.
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