Dec 12 2017

Office Door Holiday Decorations

Category: Decorations,Doors,Fire Doors,Questions and AnswersBKeyes @ 12:00 am
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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.


Nov 06 2017

Round Door Knobs

Category: Doors,Hardware,Questions and AnswersBKeyes @ 12:00 am
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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.


Oct 23 2017

Suite Entrance Doors

Category: Corridors,Doors,Questions and Answers,SuitesBKeyes @ 12:00 am
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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.


Oct 18 2017

Anteroom Door Closer

Category: Anteroom,Doors,Questions and AnswersBKeyes @ 12:00 am
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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.


Sep 14 2017

Wedging Doors Closed

Category: Door Locks,Doors,Questions and AnswersBKeyes @ 12:00 am
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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.


Aug 25 2017

Smoke Barrier Doors

Category: Doors,Questions and Answers,Smoke BarrierBKeyes @ 12:00 am
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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.


Aug 23 2017

Are Smoke Barrier Doors Required to be Inspected in Hospitals?

Category: Doors,Questions and Answers,Smoke Barrier,TestingBKeyes @ 12:00 am
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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.


Jul 12 2017

Door Undercuts

Category: Doors,Fire Doors,Questions and AnswersBKeyes @ 12:00 am
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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 8.3.3.1 of the 2012 Life Safety Code, you must install fire-rated door assemblies in accordance with NFPA 80-2010. Section 4.8.4.1 of NFPA 80-2010 says the clearance under the bottom of the door shall be a maximum of ¾ inch. Also, section 7.2.1.15.2 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 www.idighardware.com), but there may be more:

Zero:  http://idighardware.com/2013/03/solution-for-oversized-undercuts/

NGP:  http://idighardware.com/2015/01/new-products-for-oversized-fire-door-clearances/

Crown:  http://idighardware.com/2014/06/a-fire-door-test-first-hand/


Jul 05 2017

Doors Wedged Open

Category: Doors,Fire Doors,Questions and AnswersBKeyes @ 12:00 am
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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 19.3.6.3.10 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 19.3.6.3 “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 19.3.7.8 (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 19.2.2.2.7 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 7.2.1.8.2. 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 8.3.3.1 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.


Jun 05 2017

Poly Vinyl Mural on Fire Doors and Walls

Category: Doors,Fire Doors,Questions and Answers,WallsBKeyes @ 12:00 am
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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.


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