Q: I’d like some clarification concerning the new requirement for annual fire door inspections: NFPA 101 2012, Chapter 184.108.40.206 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 220.127.116.11.1 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 18.104.22.168.1 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 22.214.171.124.1 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 126.96.36.199.1 are tested and inspected in those areas.
But look at section 188.8.131.52.1.1 which refers to fire-rated doors and at the end of this section, it says “See also Section 184.108.40.206”. Section 220.127.116.11 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 18.104.22.168.2) 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.