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FAQ | January 17, 2018

Do All Fire Doors in a Facility Need to be Maintained?

This question often sparks debate among fire protection specialists and fire safety experts – clearly many door openings in a building may be equipped with fire protection rated doors, hardware and frames, although by nature of its location would not be necessitated in order to meet codes and standards. Is it the intention of adopted codes and standards for these doors to be maintained in the same manner as other fire protection rated doors located in fire walls, fire and smoke barriers? Nowhere in facility fire safety maintenance is the answer to that question more critical than in health care occupancies where strict adherence to codes and standards is obligatory.

This vital issue of code compliance was raised pending adoption of the 2012 edition of Life Safety Code by the Centers for Medicare & Medicaid Services (CMS). In a June, 2016 meeting, the National Fire Protection Association’s (NFPA) Healthcare Interpretations Task Force (HITF) that represents officials from CMS and other health care accrediting organizations including The Joint Commission issued an interpretation of the question of door inspection and maintenance and stated in part that ‘the provisions of NFPA 80 do not apply’ where a fire door label has been removed, and it ‘can be considered the same as rendering the door as other than a fire protection rated door.’ Since it was considered a matter of code compliance to maintain features of fire protection deemed to be obvious to the public, it is important for facility managers to take appropriate action.

Hospital staff striving for accreditation by the Joint Commission in particular have become very familiar with the requirements in accreditation standard LS.01.01.01 to develop and have readily available life safety drawings that accurately depict all locations of fire and smoke barriers. The need for accurate life safety drawings, however extends beyond just health care facilities accredited by the Joint Commission, as it really encompasses all long-term care and hospice facilities, ambulatory surgical facilities and limited-care facilities to name only a few. When life safety drawings are kept up to date and reflect the original fire protection construction measures that were designed and constructed, it is more readily discernable which fire doors are not necessary and could be de-labeled as such. To assist facility managers with this task, AEGIS has partnered with Emerson Graham & Associates, Fire Protection Engineers and Code Consultants licensed in Virginia and North Carolina, for necessary life safety analysis to institute a proactive approach to fire door inspection and maintenance compliance, as well as reducing the unnecessary burden to maintain non-code required equipment. Could your facility benefit from these services? AEGIS is ready to put this consultation at your fingertips – find out more at aegisfiredoor.com/code-consulting/.

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– Justin B. Biller, P.E., CLSS-HC, CFPS | AEGIS Technical Director

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