Get ready to focus on fire doors

One of these days, The Centers for Medicare & Medicaid Services (CMS) will finally adopt the 2012 edition of the Life Safety Code (NFPA 101) and a variety of new compliance requirements will need to be integrated into your operation. While I’m not here to speculate when this change will occur, it is important for providers that are subject to CMS regulations or other authorities having jurisdiction that enforce this edition code to be prepared for some significant code changes—including a requirement for inspection and testing of fire-protection-rated doors in healthcare facilities.

The National Fire Protection Association (NFPA) has published an excellent and concise article in the January/February 2016 edition of the NFPA Journal that will give hospital and long-term care providers a comprehensive understanding of these new requirements.

The article entitled “Our doors, ourselves” provides the specific code references to the different editions of NFPA 80 (currently known as the Standard for Fire Doors and Other Opening Protectives, 2010 edition) that factor into this new requirement. Some of the points highlighted in the article include:

  • Inspection frequency (annual)
  • Identification of the items of the door assembly that must be inspected
  • Operability
  • Removal
  • Replacement
  • Repairs
  • Wear and tear
  • Responsibilities and Qualifications
    • Owners/facilities managers
    • Fire door inspectors
    • Authorities having jurisdiction (AHJ)

In essence, providers will be required to have qualified staff conduct this inspection process, which includes proper documentation on an annual basis, or else engage a qualified contractor to complete the work. Additionally, AHJs will be required to have an adequate understanding of this process to help ensure proper enforcement of this code provision.

While there still may be some time before these new requirements are implemented, it is essential for providers to educate their facilities management and maintenance teams on this matter to avoid unnecessary deficiencies for failing to comply.

Please don’t consider this requirement just another compliance headache. As a former firefighter and fire marshal, I know the critical importance of a door that is designed to separate one space from another. In a true fire emergency, it can be the difference between life and death. This new inspection, testing and documentation process will help ensure that fire-protection-rated doors receive the attention needed to operate properly and compartmentalize a building during a fire or smoke condition within a healthcare facility.

Topics: Executive Leadership , Operations , Risk Management