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 23 2017

Fire Rated Door Assembly

Category: Fire Doors,Questions and AnswersBKeyes @ 12:00 am
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Q: We are planning to install double egress doors within the corridor for the purpose of separating the clean OR area from the dirty side. The doors and frame that were ordered happen to be rated for 45-minutes. This will not be a smoke or fire barrier and the doors/frame will only extend up to the drop ceiling. Since the doors are rated for 45 minutes, do we need to maintain these doors as fire rated doors and inspect them on an annual basis?

A: Yes, you do. Section 4.6.12.3 of the 2012 Life Safety Code says existing life safety features obvious to the public, if not required by the Life Safety Code, shall be ether maintained or removed. A door and frame that are labeled that identifies the door assembly as a fire-rated door assembly is interpreted by CMS and the AOs as being “obvious to the public”. Therefore, a fire rated door assembly that is not located in a fire-barrier (as you described) would have to be maintained as such and be tested and inspected on an annual basis, because the label is ‘obvious to the public’.

However, if the label is not obvious to the public (meaning it is on top of the door) then it would not have to be maintained as a fire-rated door assembly. Also, if you wanted to delete this door from the list of fire-rated doors that are tested and inspected on an annual basis, then you may remove the fire-rated label and it is no longer obvious to the public.

I’ve been told by reliable individuals that NFPA does not believe that a fire-rated label is obvious to the public, and I would not disagree with them. But they are not the AHJs. CMS and the AOs are AHJs, and the informal interpretations from them says the label is obvious to the public.

If you don’t want to test the door every year, take the label off. But be advised, you can never place that label back on if you change your mind. You would have to have it re-inspected by a UL listed company who inspects doors for re-labeling.

 


Oct 26 2017

Fire Door Inspections

Category: Fire Doors,Questions and AnswersBKeyes @ 12:00 am
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Q: Other than the annual fire door inspection that is required in the 2012 Life Safety Code, are there other inspections required? Fire doors that are included are also single fire rated doors in places like store rooms and maintenance shops, correct?

A: I’m not sure I understand your question. When you ask ‘are there any other inspections required?’… are you asking if there are any other inspections required of the fire doors? If so…. I am not aware of any. But if you’re asking are there any other inspections required in the 2012 LSC… then the answer is yes. If you’re asking if there are any other new inspections required by the 2012 LSC then I’ve included a list of changes required by the 2012 LSC that include these new inspections. In summary, new inspections are:

  • Monthly inspections of sprinkler pressure gauges
  • A quarterly main drain test on one system riser if the sprinkler water is supplied through a backflow preventer
  • A quarterly inspection of all fire hose valves
  • An annual fire door inspection
  • An annual test on all 2.5 inch fire hose valves
  • A 3-year test on all 1.5 inch fire hose valves
  • A 5-year internal inspection on sprinkler pipe

All fire rated doors must be inspected annually, regardless what they serve. So fire doors on storage rooms and maintenance shops must be included.


Oct 24 2017

Fire Door Testing

Category: Fire Doors,LSC,Questions and Answers,TestingBKeyes @ 12:00 am
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Q: Now that we have some clarification from CMS on annual door inspection [See CMS S&C memo 17-38, dated July 28, 2017], I wanted to see if there was any new interpretation on rated corridor doors (20 minute and up) that are installed in non-rated wall assemblies. In looking at most publications from different authorities, they have interpreted that all rated doors need to be annually inspected since it could be obvious to the public. Section 4.6.12.3 of the 2012 Life Safety Code says existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. However, 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 Chapters 6 through 10, the requirements of Chapters 11 through 43 shall govern. If the chapters 11-43 govern over chapters 1-10 why are the authorities not recognizing 19.3.6.3.3 where it states compliance with NFPA 80 shall not be required? Unfortunately, it doesn’t say this for “smoke barrier” doors, so the authority’s logic could still have reason. In my interpretation of 4.6.12.3 and reading the appendix it seems that NFPA is referring to first response Life Safety features, like a pull station, fire extinguisher, strobe lights, fire panels etc….. If Joe Public is seeing a fire door do its thing, it’s probably too late. Certainly, first response LS features should always work even if they are not required.

 A: You make many excellent points. But the way I see it (and interpretations by most of the AOs and CMS agree), section 8.3.3.1 of the 2012 LSC requires compliance with NFPA 80 for fire doors and windows. There are no exceptions in 8.3.3.1 that exclude fire-rated doors located in non-fire-rated barriers. Compliance with 8.3.3.1 is required by section 19.1.1.4.1.1. Where section 19.3.6.3.3 says compliance with NFPA 80 is not required, they are speaking about non-fire-rated corridor doors, which are in smoke partitions that separate a corridor from another area or room.

Smoke barrier doors are often not corridor doors; they are cross-corridor doors. But at times, a smoke barrier can (and does) include a corridor wall and what appears to be a corridor door is now also a smoke barrier door. In those situations, the hospital has to comply with the most restrictive requirements.

To me, it is plain: If you have a fire-rated door (regardless if it is located in a fire-rated barrier or not), then it must comply with NFPA 80 and you must test and inspect it on an annual basis.  I’ve been told that the opinions from the staff at NFPA do not agree with this, but NFPA does not enforce the LSC, so we need to comply with those interpretations made by the authorities who enforce the Life Safety Code, such as CMS and the AOs.

 


Sep 28 2017

Testing of Smoke and Fire Doors

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am
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Q: With regards to the 2012 edition of the Life Safety Code and the requirement to perform annual inspections of smoke/fire doors, would it be safe to assume that annual for “year one” would be between August 2016 and August 2017 and even beyond if we apply the +/- days to the annual requirement? We are having trouble trying to get everything done am hoping we can push out the new annual door inspection tasks.

A: First of all, I do not believe that smoke doors in healthcare occupancies are required to be inspected. Yes… section 7.2.1.15.2 of the 2012 LSC says (in part) smoke door assemblies need to be tested. But that conflicts with the occupancy chapter for healthcare and section 4.4.2.3 says when specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the occupancy chapter shall govern. Section 19.3.7.8 says doors in smoke barriers shall comply with section 8.5.4. Section 8.5.4.2 says where required by chapters 11 – 43 doors in smoke barriers that are required to be smoke leakaged-rated, must comply with section 8.2.2.4 (which requires testing). Chapters 18 & 19 (healthcare occupancies) do not require smoke doors to be smoke leakaged-rated: Therefore, smoke barrier doors do not have to be tested in healthcare occupancies.

Now… you may have a state agency that believes differently. Ultimately, they are an authority and if they say you have to test smoke doors, then you have to test smoke doors. But it is not required in healthcare occupancies according to the 2012 LSC. Also, some authorities say that healthcare occupancy doors in 7.2.1.15.1 must be tested, even if they are not fire-rated doors. This also is incorrect. The doors identified in 7.2.1.15.1 do not apply to healthcare occupancies so they are exempt from having to be tested. Only doors in assembly occupancies, educational occupancies, and residential board & care occupancies need to comply with 7.2.1.15.1.

But be aware: If you have areas of your healthcare facility that qualify as assembly occupancy, even if you do not declare that area as assembly occupancy, then you must comply with 7.2.1.15.1 and test those doors. This would include doors in assembly occupancies that:

  • Have panic hardware or fire-rated hardware;
  • Are located in an exit enclosure;
  • Are electrically controlled egress doors;
  • Delayed egress, access-control, and elevator lobby locked (per 7.2.1.6).

Secondly, CMS has stated that they require the first test/inspection of the fire doors to be completed by July 5, 2017. This date is based on the effective date of the 2012 Life Safety Code (which was July 5, 2016), and the fact that the fire door testing is an annual event. So, the first annual inspection is not due until July 5, 2017. I know the Accreditation Organizations will follow suit.

By the way… CMS has stated they do not approve of the ‘+’ portion of due dates. In other words, if the accreditation organization says annual means 12 months from the previous test, plus or minus 30 days, CMS is saying they do not approve of the ‘plus 30 days’. They don’t mind the ‘minus 30 days’ but they do not approve of any test/inspection going beyond what is required for a due date.


Sep 20 2017

Fire Door Annual Test & Inspection

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am
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Q: I’d like some clarification concerning the new requirement for annual fire door inspections: NFPA 101 2012, Chapter 7.2.1.15 States “Where required by Chapters 11 through 43, the following door assemblies shall be inspected ….”. I haven’t found anything in Chapters 18 or 19 that specifically require the annual inspection. Additionally, the NFPA 101 Handbook specifically states that only occupancies requiring inspections are Assembly, Educational, Day-Care and Residential board and care. My question is where is the specific reference that is requiring hospitals to conduct annual fire door testing?

A: What you stated was actually section 7.2.1.15.1 which does not refer to fire-rated doors, but to certain doors in high-traffic areas, or doors of high importance, such as doors equipped with panic hardware, doors in exit enclosures, electrically controlled doors, or doors with special locking arrangements. Now some of these doors may be fire-rated, but section 7.2.1.15.1 does not specifically refer to fire-rated doors. Therefore, that is why this section is only required if the occupancy chapter requires it and you’re correct in saying the healthcare occupancies do not require it.

And you’re correct: These doors are only required to be tested in occupancies where the occupancy chapter specifically requires it. The healthcare occupancy chapters and the ambulatory healthcare occupancy chapters and the business occupancy chapters do NOT require it, so the test and inspection identified in 7.2.1.15.1 are not required in healthcare, ambulatory healthcare, and business occupancies. Now, if you have mixed occupancies in your hospital and have areas that could qualify as assembly occupancy (i.e. dining areas, auditoriums, large conference rooms, etc.) then you would have to make sure the doors identified in 7.2.1.15.1 are tested and inspected in those areas.

But look at section 19.1.1.4.1.1 which refers to fire-rated doors and at the end of this section, it says “See also Section 8.3.3.1”. Section 8.3.3.1 requires openings that are required to have a fire-protective rating (i.e. fire-rated doors) shall be protected, by approved, listed labeled fire door assemblies with the requirements of NFPA 80. Since NFPA 80 requires annual test and inspections of all fire doors, this is the section (not 7.2.1.15.2) that requires you to test and inspect your fire-rated doors.

The CMS S&C memo 17-38 which was issued on July 28, 2017, describes this issue as well. CMS re-adjusted their expected completion date for the first fire-door test and inspection from July 6, 2017 to January 1, 2018, but not all of the Accreditation Organizations followed suit. Check with your authorities having jurisdiction to confirm what date they are expecting you to complete your first fire-door test and inspection.


Jul 27 2017

AHJ on Fire Door Inspections

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am
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Q:  Does the authority having jurisdiction have the final say whether or not an individual has the ‘knowledge and understanding’ required to perform fire door inspections?

A: Yes they do. Take a look at 4.6.1.1 of the 2012 LSC “The authority having jurisdiction shall determine whether the provisions of this Code are met.” That means the AHJ decides if the organization is compliant with the applicable NFPA codes and standards. But, keep in mind the typical hospital has 5 or 6 different AHJs that inspect their facility for compliance with the LSC:

  • CMS
  • Accreditation organization
  • State health department
  • State agency with over-sight on hospital construction
  • State fire marshal
  • Local fire inspector
  • Liability insurance company

Not one AHJ can over-ride another AHJ’s decision. All AHJs are equal… but different. If 5 AHJs say the qualifications of the person performing the fire door inspections are fine, but 1 AHJ says no, then the hospital must comply with the most restrictive requirements and comply with the latter AHJ’s desires. An AHJ may have rules and requirements that exceed NFPA standards, as well they should. NFPA standards are minimal standards, and most hospitals exceed the NFPA standards in some capacity, often due to local ordinances or state regulations (and sometimes at the whim of the design professional). But, if the AHJ decides to have standards that exceed the minimal NFPA requirements, they need to be able to justify that decision.

It is not at all uncommon for a healthcare organization to seek permission from a state or local AHJ (i.e. state fire marshal) to install a particular device or have a particular feature, only to find out later that their accreditation organization does not agree, and cites the issue. Both the state or local AHJ and the accreditation organization are correct; they are interpreting the Life Safety Code as they see fit. Whatever was approved by the state or local AHJ is just an approval for the state or local regulations. What was cited by the accreditation organization was cited based on the accreditation organization’s regulations and understanding of the Life Safety Code.

This is why healthcare organizations need to obtain permission and interpretations from all of their AHJs… not just one or two.


Jul 26 2017

Fire Rated Doors in Non-Fire-Rated Walls

Category: Fire Doors,Questions and AnswersBKeyes @ 12:00 am
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Q: If a fire door is in a wall that is not a fire-rated wall, will the wall need to be brought to be a fire-rated wall?

A: No… not typically. The location of fire-rated barriers (i.e. walls) are determined by the design professional (i.e. architect) when the facility is designed and constructed. Often times, after the facility is built and operating for a few years, new locations that require fire rated barriers are identified. These could include rooms that are newly designated as hazardous areas, or perhaps a building separation from a new addition.

It is not uncommon for some design professionals to specify fire-rated door assemblies in barriers that are not fire-rated. This may be due to a building code requirement, or it may be due to a misunderstanding of the codes and standards. For whatever reason, once these fire-rated door assemblies are installed, you must maintain them in accordance with NFPA 80 which includes annual fire-door testing and inspections. But there is no requirement to designate a barrier to be labeled as a fire-rated barrier simply because it has a fire-rated door assembly installed in it. To be sure where the fire-rated barriers are actually located, refer to the Life Safety drawings and/or original construction documents of the facility.


Jul 20 2017

Fire Door Inspection Qualifications

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am
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Q: In regards to fire door inspections, what are the qualifications of the person to perform the inspection?

A: NFPA 80-2010, section 5.2.3.1 says fire doors must be tested by individuals with knowledge and understating of the operating components of the door assembly, but NFPA 80 does not identify or describe what ‘knowledge and understanding’ actually means. The word ‘qualified’ is not found in this context of describing the individual who performs this inspection. When the codes or standards are vague (as they often are), then it is up to the authorities having jurisdiction to decide how to interpret the code or standard (see 4.6.1.1 of the 2012 LSC). When the AHJ does not make an interpretation of the code or standard, then it is up to the individual facility to decide what’s right.

In this case, no national AHJ has published an interpretation for hospitals on what ‘knowledge and understanding’ is required to test and inspect fire door assemblies. Therefore, hospitals and other healthcare organizations have the right to decide what that means. However, during a survey or an inspection, the AHJ surveyor has the right to question how the hospital determined their individual has the ‘knowledge and understanding’ and if it is not satisfactory to the AHJ surveyor, then a citing may be in order.

My advice to healthcare organizations on this issue is to document why they believe their individual has the ‘knowledge and understanding’ to perform the inspections. If their maintenance person has worked on fire doors for 20 years then that may be sufficient evidence.

I also recommend healthcare organizations to sign their people up for an online course on fire door inspections, by using the link and coupon code located at the right-hand side of this web-page, to the International Fire Door Inspector Association (IFDIA).


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/


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