When the new 2012 Life Safety Code becomes effective July 5, 2016, CMS will expect all healthcare organizations to be compliant with the requirements of the new 2012 Life Safety Code. One of the more challenging changes that the new 2012 Life Safety Code will require is compliance with NFPA 80-2010 edition, which requires all fire-rated door assemblies to be inspected annually.
This includes all of the side-hinged swinging fire-rated doors in your facility. And it applies to any fire rated door assembly, whether it is located in a required fire rated barrier or not.
The requirements for the annual inspection include the following:
- Is the door and frame free from holes and breaks in all surfaces?
- Are all the glazing, vision light frames and glazing beads intact and securely fastened?
- Are the doors, hinges, frame, hardware and threshold secure, aligned and in working order with no visible signs of damage?
- Are there any missing or broken parts?
- Is the clearance from the door edge to the frame no more than 1/8 inch?
- Is the door undercut no more than ¾ inch?
- Does the active door leaf completely closes when operated from the full open position?
- Does the inactive leaf close before the active leaf when a coordinator is used?
- Does the latching hardware operate and secure the door in the closed position?
- Is the door assembly free from are auxiliary hardware items which could interfere with its operation?
- Has the door been modified since it was originally installed?
- If gasketing and edge seals are installed, have they been verified for integrity and operation?
Anyone can do this inspection… there is no requirement that the inspector has to be certified. But the standard does require that the individual inspecting the door assembly is knowledgeable, so if you plan on using in-house people, make sure they have some sort of training. The IFDIA certification (see side panel) is one of many on-line courses to become trained for fire door inspections.
There is a Fire Door Inspection form you may down-load for free from this website. Just click on “Tools” and scroll down to the bottom to find it.