Door Undercuts

Q: What is the maximum you can have between the bottom of door and the thresholds for a fire-rated door assembly? I have some stairwell doors with 1 inch to 1 ¼ inch gap between the bottom of the door and the threshold.

A: That will be a problem. According to section of the 2012 Life Safety Code, you must install fire-rated door assemblies in accordance with NFPA 80-2010. Section of NFPA 80-2010 says the clearance under the bottom of the door shall be a maximum of ¾ inch. Also, section of the 2012 Life Safety Code says you must maintain the fire rated door assemblies in accordance with NFPA 80.

Any clearance under the bottom of the door (while it is in the closed position) that exceeds ¾ inch will be considered non-compliant. There are after-market devices available that you can install on the door to fill that gap, but you must be very careful as you can only install devices that have been listed by an independent testing laboratory (i.e. UL, FM Approval, Intertek) that have been approved for that purpose.

Keep in mind that there are limitations on the door material, amount of clearance, and the rating.  Here are links to information on 3 products suggested to me by Lori Greene (see her website at, but there may be more:




Doors Wedged Open

Q: It has been our practice to not allow door hold open wedges on any door within the hospital. As far as code requirements go is it rated doors only, or does it include any door with a closer?

A: It applies to any fire rated door assembly, any non-rated door assembly that is required to be self-closing, and all corridor doors regardless of their fire-rating and regardless if they are self-closing.

Look at section of the 2012 LSC, which says doors shall not be held open by devices other than those that release when the door is pushed or pulled. This section is part of section “Corridor Doors” so it is referring to corridor doors only. Approved ‘push or pull’ release devices to hold a door open are the friction-fit type hold open that are integral to the door closer, and magnets. The logic here is a person could quickly push or pull the door closed, but if the door was wedged open, then the closing of the door would be slower and more difficult; therefore, wedging a door open would not be permitted.

Section (1) of the 2012 LSC says doors in smoke barriers must be self-closing. The term ‘self-closing’ means the door has to close by itself without assistance. A smoke barrier door that is wedged open will not close by itself. Section 3.3.238 of the 2012 LSC defines “Self-closing” as a door equipped with an approved device that ensures closing after opening. All doors in hazardous areas are required to be self-closing regardless if the door is fire-rated or just smoke resistant.

To further make the point, section of the 2012 LSC says any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by automatic release device that complies with The implication here is these doors must be self-closing and may only be held open by a device that releases the door (and allows the door to self-close) upon activation of the fire alarm system or sprinkler system.

And to finally address fire-rated door assemblies, section requires all doors required to have a fire protection rating to comply with NFPA 80, which requires self-closing devices on the doors. So, any fire-rated door assembly may not be wedged open.

That applies to nearly all doors in a hospital. But there are some doors that you could actually wedge open, although you probably would not want to inform your staff. Doors located inside a suite of rooms that do not serve an exit or a hazardous area would be permitted to be wedged open because those rooms inside a suite are not required to have doors. But that’s about it.

Poly Vinyl Mural on Fire Doors and Walls

Q: Is it permissible to completely cover a fire rated door in a hospital with a polyvinyl picture/mural? Also, is it permissible to cover a fire rated wall, from floor to ceiling in hospital with the same product?

A: No. You are not permitted to cover a fire-rated door with anything. Period. The reason why is, whatever is placed on the door will likely change the fire-resistive characteristics of the door and may likely allow the door to not last as long as it is designed.

Assuming the mural is newly installed, a poly-vinyl picture mural on the walls of the hospital may be permitted if it meets the requirements for interior finish. Class A interior finish is permitted on walls, and Class B is permitted in rooms where the capacity does not exceed four persons. A Class A material has a flame spread rating of 0 -25, and a Class B materials has a flame spread rating of 26 – 75.

Ask your supplier/vendor to provide the interior finish classification or the flame spread ratings to determine if you are compliant.

Lower Bottom Rods

Q: I have been asked about the requirements for the use of the lower bottom rod hardware in cross-corridor egress doors which provide positive latching and building separation. For aesthetic reasons, we wish to remove the bottom flush bolts, allowing for the floor to be void of the ‘ugly’ recessed catch. Is it required by code to have the lower bottom rod, or is this more of a question for the hardware manufacturer?

A: The lower bottom rod latching system is there because the manufacturer of the door hardware says it has to be there; not because there is a code or standard that requires it. It’s there because the manufacturer received a UL listing (or other independent laboratory listing) saying that is how they secure the door during a fire.

If it is a fire-rated door, then according to section of the 2012 Life Safety Code, you are required to maintain the door to be in compliance with NFPA 80, which requires the fully compliment of hardware that the manufacturer says is required.

Some door hardware manufacturers have been able to obtain UL listings without having the lower bottom rod, and that is entirely an issue between the manufacturer and the testing laboratory. Some door hardware manufacturers have been able to obtain a listing to remove the lower bottom rod and replace it with a fire-pin… a fusible link mounted inside the door that secures the door during a fire.

Work with the manufacturer of the door hardware. Do what they say is required in order to maintain the fire rating of the door assembly. A missing lower bottom rod is likely to be observed during a survey and if you have documented proof from the door hardware manufacturer that the lower bottom rod is not required then you should be safe.

Positive Latching Doors

Q: Is positive latching required for any fire rated door in any occupancy classification? If so, are there any exceptions? What about double egress corridor doors; are they required to be positive latching? Are doors to restrooms required to be positive latching?

A: Yes, fire rated doors are required to positively latch no matter where they are installed, according to section of the 2012 Life Safety Code. This section requires all fire rated doors to be compliant with NFPA 80, which requires positive latching hardware. This is a requirement for all occupancies, and is not specific to any one occupancy. There are no exceptions as far as I know: If the door is a fire rated door assembly then it needs to positively latch.

This raises the awareness about barriers that do not require fire rated doors. It is not uncommon for an architect to require all doors in a corridor to be 20-minute fire rated doors, even if the corridor walls are not fire rated. In situations like this, the doors would be required to be positive latching from two different code references: 1) Because the door is a fire rated door and section requires it to comply with NFPA 80 which requires positive latching; but also 2) Because corridor doors are required to latch, according to section However, all of the other NFPA 80 requirements concerning fire rated doors (i.e. self-closing door and fire rated frames) applies since section requires features of life safety that are obvious to the public to be maintained even if they are not required.

If the double egress corridor doors are required to be fire rated, then they too must positively latch. But not all double egress doors in a corridor are required to be fire rated. Double egress doors that serve a smoke compartment barrier are not required to latch, according to section 18/

In regards to public restroom doors: According to section, exception #1, these doors are not required to latch, provided they are not fire-rated doors. It is quite rare to find an entrance door to a restroom that is fire rated.

Office Door Swing

Q: Does a corridor door that serves an office have to swing into the office? The office is on a patient floor and the door does not serve as any other type of door.

A: According to section of the 2012 Life Safety Code, the door is permitted to swing into the corridor, but during its swing, it cannot obstruct more than ½ of the required width of the corridor. And when the door is fully open (up against the wall), it cannot extend more than 7 inches into the corridor.

If the door swings into more than ½ of the required width of the corridor, then that is a problem. Likewise, if the door extends out into the corridor more than 7 inches when it is fully opened, then that also is a problem.

But the FGI Guidelines has a requirement that prevents doors from swinging into the corridor for new construction, so check with your state or local authorities to s ee if they have more restrictive requirements.

Windows in Patient Sleeping Rooms

Q: In the 2000 edition of the Life Safety Code, under section 18.3.8 “Special Protection Features -Outside Window or Door”, they have requirements for windows or doors to the outside in patient sleeping rooms. However, in the 2012 edition of LSC, under section 18.3.8 “Special Protection Features (Reserved)”, it does not list any requirements for windows or doors to the outside in patient sleeping rooms. Does this mean that outside windows or doors are no longer required?

A: You have touched on an issue that is not often discussed. Yes, you are correct: The 2000 LSC did require a window or door to the outside in patient sleeping rooms. Up until the 1994 edition, the LSC required those windows and doors to operate, to allow venting during a fire emergency. In the 1994 edition, the LSC changed to stop requiring the windows to operate, but the requirement for the windows or doors remained. In the 2009 edition, the LSC deleted the requirement for windows or doors to the outside in patient sleeping rooms all-together, because the technical committee feels the total concept approach in section 18/ covers the issue of evacuation, and no longer requires such an opening.

However… that does not mean you can design new hospitals without windows in patient sleeping rooms. Many local building codes, and state agencies with authority over hospital construction, still require windows in patient sleeping rooms in hospitals. There is a psychological need for the patient to see the outside light of day in the recovery process. The problem is, the LSC does not deal in the psychological needs of patients… at least not on this issue.

I also reviewed the Final Rule that CMS issued last May when they adopted the new 2012 LSC. Sometimes, CMS will retain a requirement in an older version of the LSC even though the newer version no longer requires it. In this case though, CMS did not say anything about keeping the requirement for windows in patient sleeping rooms.

But I suggest you check with your state and local authorities to determine if they have any regulations on this issue.

Construction Barrier Doors

Q: Does a door that accesses a construction site within a hospital need to have an automatic closer installed on the access door? What if the door is constructed within temporary drywall barriers?

A: The 2012 Life Safety Code references the 2009 edition of NFPA 241 which has changed from previous editions to require fire-rated barriers separating construction areas from occupied areas. The 2009 edition of NFPA 241 now requires all construction areas to be separated from occupied areas with 1-hour fire rated construction, which will include ¾ hour fire rated doors that are self-closing and positive latching. There is an exception in the 2009 NFPA 241 that allows non-fire rated barriers if the construction area is protected with automatic sprinklers, but the Annex section of NFPA 241 specifically says ‘construction tarps’ would not be permitted. It is unclear if using flame retardant plastic visqueen to separate construction areas from occupied areas would be permitted since the standard does not allow tarps. The NFPA HITF committee began to deal with this issue but failed to come to a consensus.

That means steel studs and gypsum board would still need to be used to separate construction from occupied areas, however if the construction area is sprinklered then the separation barrier would not be required to be 1-hour fire rated. The construction area would still be considered a hazardous area which requires a self-closing door.

Egress Hardware

Q: We have “clinic” type areas within suites.  Some of these doors that lead to the main corridor for egress, have regular “turn handle” type handles.  Not panic hardware.  What is the mindset of where it is required to have panic hardware on a door, and when turn handles are permitted?  Is there a “rule of thumb” on when a door has to have panic hardware for egress?

A: Horizontal egress hardware on a door (commonly referred to as crash bars and often misnamed panic hardware) are not required in a healthcare occupancy. Crash bars are required on doors in the path of egress from assembly occupancies. So, if a hospital has a dining area or an auditorium; these are assembly occupancies areas, and horizontal crash bars would be required even if the entire area is classified as healthcare occupancy. Section of the 2012 Life Safety Code requires where there is a mixed occupancy (meaning the different occupancies are not separated with a 2-hour fire rated barrier), then the more restrictive requirements of the occupancies involved must be followed. Therefore, since an auditorium and a dining area (50 or more people) exist inside a hospital, then the requirements of assembly occupancy must be followed. Horizontal crash bars would then be required.

But there is no requirement for horizontal crash bar hardware on egress doors from a hospital suite as you described.

Corridor Door Louver

Q: Is there a code that says anything about adding a vent through a door that is in the corridor of our hospital?

A: Well… you might be able to do that legally on a very few specific corridor doors (i.e. bathroom doors, toilet rooms doors, shower room doors), but no, you cannot install a louver in a typical corridor door in a hospital because section of the 2012 LSC says corridor doors have to resist the passage of smoke. Therefore, a louver in a door would not resist the passage of smoke.

Now, a very few specific corridor doors do not have to resist the passage of smoke as described in section (1), and you would be permitted to install a louver in those doors.