Suite Entrance Doors

Q: A hospital has 2 different suites with double egress entry doors and the Joint Commission surveyor noted that these doors are supposed to have latching hardware because they are “corridor doors,” but in my experience, cross-corridor doors are not typically required to have latching hardware.  Can you weigh in on this?

A: I agree totally with the surveyor. According to the LSC, suites are nothing more than rooms; albeit a large room with smaller rooms inside. Therefore, corridor entrance doors to suites must positively latch because corridor doors are required to latch according to 18/19.3.6.3.5, 2012 LSC.

The thing that throws people off is what looks like a corridor inside a suite is not a corridor; it is a communicating space. The requirements of a corridor do not apply inside a suite. But the designers often make this space 8 feet wide and for all intent and purposes people think it is a corridor. Then, the designer places double egress doors as entrances to the suite (which is good when you’re pushing patients in an out on beds) and the doors look like cross-corridor doors. They’re not; they are corridor doors.

The hospital has to make those doors positively latch or they have to change the designation from a suite to a corridor, which is not advisable.

Closers on Doors to CT Scan

Q: Do entrance doors to x-ray rooms and CT scanner rooms have to be controlled by door closers?

A: According to the Life Safety Code, they only need closers if they are considered to be hazardous rooms (normally not) or if the door in question is also part of the smoke compartment barrier wall. However, other codes and standards may apply. Be sure to check with your state and local authorities.

Office Door Holiday Decorations

Q: Staff members at our behavioral healthcare facility enjoy decorating their corridor office doors (business occupancy, 20-minute fire-rated doors, multiple floors) with wrapping paper, bows, etc. affixed with scotch tape for the holidays. Are there specific prohibitions against this? We don’t want to be a Grinch unless necessary. thanks!

A: Section 7.1.10.2.1 of the 2012 LSC says decorations cannot obstruct the function of the door or the visibility of the egress components. So, the decorations cannot obstruct the door in any way.

Section 4.1.4.1 of NFPA 80-2010 says signage on fire-rated doors cannot be more than 5% of the door surface. Now decorations may not be considered signage by most individuals, but the intent is to keep the fire-load on the door to a minimum so it can function properly in the event of a fire. I can see where a surveyor would have a serious issue with decorating fire-rated doors with wrapping paper and bows, because it adds fuel to the door that was not present during the UL testing of the doors.

Sorry, but I suggest you be the Grinch and tell them to remove wrapping paper and bows from the fire-rated doors.

Round Door Knobs

Q: Our hospital has round door knobs to latch cross corridor smoke doors. I am thinking this is not okay. Does the Life Safety Code address this?

A: Other than section 12.2.2.2.3 of the 2012 LSC that requires panic hardware on egress doors (or fire-exit hardware on fire rated doors) in Assembly occupancies (or mixed occupancies that include Assembly occupancy areas) that serve 100 or more persons, there is nothing in the Life Safety Code or NFPA 80 that prevents the use of round door knobs on doors that you describe.

However, round door knobs could present a safety risk for ligature if they were located in an area where behavioral health patients are located. This risk would have to be addressed in a risk assessment and mitigation activities implemented. But the LSC does not prohibit them.

Suite Entrance Doors

Q: We have a double egress, cross-corridor door which will enter a suite under a renovation project. The suite wall is also an existing smoke barrier wall, separating smoke compartments. However, we do not want an exit route through the suite, as this would be a code violation. The new layout will not cause a dead-end corridor and the suite will house less than 50 people. Is it allowable to replace the double egress door with a pair of out swinging doors?

A: As long as the new doors are not cross-corridor doors, I believe you can have a pair of single-egress doors as an entrance to the suite in a smoke compartment barrier. Under section 18.3.7.6 of the 2012 LSC, all new cross-corridor doors serving a smoke compartment barrier must be the double egress type. But from your description, it appears these new doors would not be cross-corridor doors, but would be corridor entrance doors to the suite.

These new doors would have to latch because they are corridor entrance doors to a suite, even though they serve a smoke compartment barrier.

Anteroom Door Closer

Q: We have an isolation room next to a nurse station in the Emergency room. The corridor door to the Anteroom has a door closer on it. My question: does the closer have to be on the anteroom door? I know that it has to be on the Isolation room door.

A: According to the Guidelines for Design and Construction of Health Care Facilities by the Facility Guidelines Institute (FGI), 2010 edition, if you have an anteroom (whether or not the anteroom is required) then the door to the anteroom must have a self-closing device. The FGI does say that anterooms are not required for airborne infection isolation (AII) rooms, but they are required for protective environment (PE) room, or a combination PE/AII room. If your organization has a PE room for emergency room patients, then it would require an anteroom, which in turn would require a closer on the door. The Life Safety Code would not require a closer on the anteroom door; however, the FGI would take precedent over the LSC in this matter.

Wedging Doors Closed

Q: Is it allowed to use door wedges to keep the exam doors locked? If an intruder enters our hospital, there was some talk about using the door wedges to lock the doors so the intruder cannot open the doors. It was also brought up that if one person was in the room and used a door wedge and had a medical emergency, the door could not be opened to help the person. Any help you could give us would be greatly appreciated?

A: During normal operations, it would not be acceptable to wedge a door closed to an exam room or a patient sleeping room as that would cause an unsafe environment, and would likely be cited under CMS Condition of Participation standard §482.41(a) for an unsafe environment. Your intuition is correct: A wedged door would cause delay in gaining access to a patient in distress.

However, during an emergency, all “bets are off”, meaning you do what you have to do to respond to the course of the emergency. If this means you wedge the door closed to prevent an intruder from entering the room, then that’s what you do. Although you won’t find this written in any code or standard, the concept of emergency response is you do whatever is needed to provide care and safety for your patients. Wedging a door closed to prevent an intruder from entering the room would be an acceptable plan in my book. You just don’t do that during normal operations.

Power Assist Door

Q: We were cited during a recent survey for not having our power assist doors to our ICU suite connected to the fire alarm system. I thought that was only required on fire-rated doors. Is this a requirement for a corridor door?

A: Section 7.2.1.9 of the 2012 Life Safety Code is discussing Powered Door Leaf Operation, and applies to power assist and power operated doors. This section is not limited to any type of door, such as fire-rated, smoke-resistant, etc. This section applies to all doors with power assist and/or power operated. The six criterions listed under 7.2.1.9.2 must all be met in order to comply with 7.2.1.9.2. Subsection (4) under 7.2.1.9.2 discusses the situation where the door leaf is required to be self-closing or positive latching and is equipped with power operation and is left in an open position, there must a smoke detector near the door that would activate and cause the door leaf to close and cease operation. Therefore, the power assist function would have to be connected to the fire alarm system. Subsection (4) says the smoke detector must be placed in accordance with NFPA 72, so there are a couple of options:

  1. A smoke detector within 5 feet on one side of the door if the height of the transom above the door is less than 24 inches.
  2. A smoke detector within 5 feet on both side of the door if the height of the transom is 24 or more inches above the door.
  3. A smoke detector within 14 feet of the door if the entire area on that side of the door (i.e. corridor) is 100% smoke detected.

All of the above applies to any door, regardless of fire-rating, that is required to be either self-closing or positive latching and is equipped with power assist or power operated equipment. Yes… it applies to suite entrance doors, because the suite is a room that is separated from the corridor and according to 19.3.6.3.3, corridor doors must latch.

Smoke Barrier Doors

Q: Are smoke barrier doors and frames required to have a fire rating label?

A: No. This seems to be a difficult issue for many people (including surveyors) to grasp. According to section 19.3.7.6 of the 2012 LSC, doors in smoke barriers are required to be 1¾ inch thick, solid-bonded, wood-core doors, or be of construction that resists fire for at least 20 minutes. This does not mean the door and frame must be a fire-rated door. It only means the door must be of construction that resists fire for at least 20 minutes.

The confusion surrounding this issue may be found in section 8.3.4.2 of the 2012 LSC, which says doors in smoke barriers must have a fire rating of not less than 20 minutes. But whenever there is a conflict between the core chapters (chapters 1 – 11) and the occupancy chapters (chapters 12 – 42), the requirements of the occupancy chapter over-rides the requirements of the core chapter (see section 4.4.2.3). In other words; the occupancy chapter trumps the core chapters.

Section 19.3.7.8 of the 2012 LSC continues to say that doors in smoke barriers are not required to be positive latching That alone should be the tell-tale sign that the door is not required to be a fire-rated door since all fire rated doors must be positive latching (according to NFPA 80).

Some architects do specify 20-minute fire rated doors in smoke barriers, and while this practice is not a violation of the LSC, it does present a burden on the healthcare facility because now they have to maintain it as a fire rated door, even though it is not required to be a fire rated door. This causes more headaches because the 2012 LSC references the 2010 edition of NFPA 80 which will require an annual inspection of all side-hinged swinging fire doors.

Are Smoke Barrier Doors Required to be Inspected in Hospitals?

Q: Do doors in smoke barriers in healthcare occupancies have to be tested and inspected? Section 7.2.1.15.2 of the 2012 Life Safety Code says smoke door assemblies have to be inspected and tested in accordance with NFPA 105.

A: Well, the answer is no… Smoke barrier doors that are non-rated are not required to be inspected annually in healthcare occupancies, even though 7.2.1.15.2 says they do. Here’s why:

  • Section 19.3.7.8 says doors in smoke barriers shall comply with 8.5.4 and all of the following: 1) Doors shall be self-closing; 2) Latching hardware is not required; and 3) The doors do not have to swing in direction of travel.
  • Section 8.5.4.2 says where required by chapters 11 through 43, doors in smoke barriers that are required to be smoke leakage-rated shall comply with section 8.2.2.4. [NOTE: Chapters 18 & 19 for healthcare occupancies do not require smoke leakage-rated doors in smoke barriers…. Therefore, compliance with section 8.2.2.4 is not required.]
  • Section 8.2.2.4(4) says where door assemblies are required elsewhere in the Code to be smoke leakage-rated, door assemblies shall be inspected in accordance with 7.2.1.15.

CONCLUSION: Since the healthcare occupancy chapters do not require smoke barrier doors to be smoke leakage-rated, then there is no requirement to be compliant with 7.2.1.15.2 that says the smoke doors need to be inspected.

Section 4.4.2.3 says where specific requirements contained in chapters 11 through 43 differ from general requirements contained in chapters 1 through 4 and from chapter 6 through 10, then the requirements of chapters 11 through 43 govern. Since the healthcare chapters do not require smoke barrier doors to be smoke leakage-rated, then it conflicts with section 7.2.1.1.5.2, and when that happens, you follow the occupancy chapter requirements.

The problem is… not all authorities having jurisdictions (AHJs) knew this or understood this. Case in point: The Centers for Medicare & Medicaid Services (CMS) had instructed their state agency Life Safety surveyors that all smoke doors in healthcare occupancies need to be tested and inspected, citing section 7.2.1.15.2.

In addition, CMS also taught their LS surveyors that doors in healthcare occupancies that meet the requirements of 7.2.1.15.1 have to be tested as well, which is not entirely true. These doors identified in 7.2.1.15.1 only have to be tested in assembly occupancies, educational occupancies, or residential board & care occupancies. The exception is, some hospitals have mixed occupancies that include the requirements for assembly occupancies, so in those cases, yes, the doors in 7.2.1.15.1 would have to be tested and inspected on an annual basis.

But on July 28, 2017, CMS issued S&C memo 17-38 which corrected this error. In this memo, CMS says smoke barrier doors do not have to be tested in healthcare occupancies. So, they saw an inconsistency with the 2012 Life Safety Code, and corrected their position. They even admitted some confusion on their part regarding door testing in general and decided to extend the date that the first fire door test is due from July 5, 2017 to January 1, 2018. But be careful with that: Not all AHJs are moving the date that the first fire door test is required.

You can expect a similar announcement from Joint Commission, if it hasn’t happened already. I’ve been told they will changed their standards to reflect what CMS has said.