May 28 2018

Door to Compressed Gas Storage Rooms

Category: BlogBKeyes @ 12:00 am
Share

Q: I have an oxygen/med gas storage room that is attached to the hospital, and can only gain access to the room by way of the exterior of building. Does the room have to have a fire-rated door assembly?

A: Well… that depends. If the storage room contains 3,000 cubic feet or more of compressed medical gases, and the room is located indoors, then the room must be constructed with 1-hour fire-rated construction and the door to the room is required to be 1-hour fire rated if new construction, and 3/4-hour rated if existing conditions. (See 5.1.3.3.2(4) of NFPA 99-2012).

However, the intent of 5.1.3.3.2 is to separate the compressed gas storage room from the rest of the facility by requiring 1-hour fire rated barriers, and if the door opening to the storage room opens into the facility, one could easily understand why a fire-rated door is required. However, if the door to the storage room opens to the outdoors (i.e. receiving dock) then one could make a point that the door is not required to be fire-rated, because there is no separation between the storage room and the rest of the facility at that point.

But the problem is, NFPA 99-2012 section 5.1.3.3.2 does not say that and does not appear to have any exception for a door to the storage room that opens to the outdoors. I think a rational, smart, understanding surveyor would agree with that point and not cite you for not having a fire-rated door that opens to the outdoors.

But will you always have a rational, smart, and understanding surveyor?

Tags: , ,


May 07 2018

Fire Rated Door Assemblies

Category: BlogBKeyes @ 12:00 am
Share

Q: You have stated in previous Q&As that all fire-rated door assemblies must be tested and inspected. I don’t think that is true on fire-rated door assemblies that are not located in a fire-rated barrier. I was under the impression that the hospital’s current Life Safety drawings would be the determining factor on what barriers the hospital was responsible for maintaining. For example, if the building had rated doors on a wall that was not denoted as a fire rated barrier on the LS drawings, one could justify why there were not maintained. I run into the installation of unnecessary rated doors in many facilities, both old and new.

A: You make an interesting case. However, the Life Safety Code always trumps everything else, and in this case it would trump the hospital’s LS drawings. According to section 4.6.12.3 of the 2012 LSC, it clearly says all existing features of life safety that are obvious to the public, if not required by the LSC, must be maintained or removed. And section 8.3.3.1 says openings (i.e. doors) required to have fire protection must be maintained in accordance with NFPA 80 which requires annual testing and inspection.

Now, there’s a lot going on with this statement… For example: NFPA has said via informal comments that a fire-rated label on the edge of the door is not considered ‘obvious to the public’. But other AHJs disagree, and have stated that the fire-rating label on the door constitutes the need to maintain it as a fire-rated door. Most surveyors will go by the fire-rating label on the door, since a high percentage of Life Safety drawings are inaccurate to some degree.

I don’t disagree with your logic. If it were up to me, I would not require fire-rated doors that are not in fire-rated barriers to require testing and inspections. But think of it the way a surveyor does… Who is to say the fire-rated doors are not located in a fire-rated barrier? Just because the Life Safety drawings say it is not in a fire-rate barrier, what about building code requirements? Life Safety drawings do not always represent the rated wall requirements of building codes. There is too much ambiguity for a surveyor to take the word of the hospital that a certain fire-rated door is not located in a fire-rated  barrier.

My advice is to remove the fire-rated label from the door and frame if the facility is sure the door assembly is not located in a fire-rated barrier.

Tags: ,


Feb 26 2018

Fire-Rated Doors

Category: BlogBKeyes @ 12:00 am
Share

Q: My hospital is a behavioral health hospital converted from an acute hospital. The doors on patient rooms and mostly all doors in this building are solid core doors….which are fire rated. My office door and most in this wing are also lead lined. We need the solid core doors for the patient rooms due to their behavior….regular doors would be torn up quickly. How do I comply with the new ruling on fire-rated door inspections in this situation?

A: You can do one of two actions:

  1. You can test and inspect the fire-rated door assemblies on an annual basis in accordance with sections 4.6.12.3 and 8.3.3.1; or
  2. You can remove the fire-rated label on the door assemblies if the door is not required to be a fire-rated door assembly.

Even if the door is a labeled fire-rated door assembly but is located in a barrier that is not required to be a fire-rated barrier, you must still maintain the door in accordance with NFPA 80, which requires annual test and inspection. However, if the barrier is not required to be a fire-rated barrier, and you remove the labels (on the door and on the frame) then the door is no longer a fire-rated door assembly and you do not have to maintain it as such.

Tags:


Dec 09 2016

Incorrect Interpretations on Smoke Door and Fire Door Testing

Category: BlogBKeyes @ 12:00 am
Share

I just found out yesterday that CMS is teaching their state agency LS surveyors that smoke barrier doors need to be tested in healthcare occupancies. This interpretation of the 2012 Life Safety Code from CMS is incorrect, but your state agency on behalf of CMS may be expecting you to do this.

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. You may show them this code trail and perhaps they will allow you to not test your smoke doors, but 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, CMS has instructed their state agency LS surveyors 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 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).

Tags: , , ,


Jun 01 2016

New Fire Door Inspection Requirements

Category: BlogBKeyes @ 12:00 am
Share

Cross Corridor door web 2When 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.

Tags:


Apr 08 2016

Fire and Smoke Door Clearances

Category: BlogBKeyes @ 12:00 am
Share

Q: I have a question concerning clearances on fire rated doors and smoke compartment barrier doors. The way I read the 1999 Edition of NFPA 80 and the information in the 2000 Life Safety Code (LSC) is that a maximum gap of 1/8 inches is permitted between “meeting edges of door pairs”. In terms of 2000 LSC compliance would you agree that the 1/8 inch clearance on smoke barrier doors and fire rated doors is regulated at the “meeting edge of door pairs”?

A: According to the Annex section of 8.3.4.1 of the 2000 LSC, it says the clearance for the proper operation of smoke doors is defined as 1/8 inch. While the Annex section is not part of the enforceable code, it does provide a guide for authorities to use in making their own interpretations. The Annex does not limit the 1/8 clearance to just the meeting edges of a pair of doors and could be construed as meaning the edges of the door that meets with the jamb of the frame.

Section 2-3.1.7 of the 1999 edition of NFPA 80 says the clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 inch + 1/16 inch for steel doors and shall not exceed 1/8 inch for wood doors.

So, to answer your question: “In terms of 2000 LSC compliance would you agree that the 1/8 inch clearance on smoke barrier doors and fire barrier doors is regulated at the meeting edge of door pairs,?”, I would say yes it is regulated at the meeting edges of door pairs, but section 2-3.1.7 of NFPA 80 says the clearance between the edge of the door and the frame is included in the 1/8 inch limitation. So the clearance between the edges of the door and the frame are also included in the 1/8 inch requirement.

As far as smoke compartment barrier doors, I would also agree that the clearance between the meeting edges of door pairs are limited to 1/8 inch, but this is based on the current interpretation of the accreditation organizations and CMS state agencies. But I’m not so sure about the clearance between the door edge and the frame jamb as the 1/8 inch limitation is found in the Annex section, and it would have to be an interpretation by an authority since it is not written in the enforceable code. I personally do not have any experience on how accreditation organizations and CMS state agencies are surveying the issue of smoke compartment barrier door clearances between the door edge and the frame jamb. So, the clearances between a smoke compartment barrier door edge and the frame jamb is an issue that is not clearly defined at this time.

Tags:


Jan 29 2015

Frames for Fire Rated Door Assemblies

Category: BlogBKeyes @ 6:00 am
Share

Label for Fire Door FrameDuring the building tour a surveyor observed a label on a frame for a fire rated door assembly that read “Fire Resistant Frame – This frame is identical in construction to a listed frame.  This frame does not bear a listing mark of a testing laboratory because of size, hardware preparation or other limiting factors specified by the user/owner”.  The surveyor initially decided to cite the organization for not having a frame that has  an hourly fire rating on the fire rated door assembly.

Before the survey report could be finalized, it was brought to the surveyor’s attention that NFPA 80 does not require an hourly rating on fire rated door assembly frames. According to NFPA 80, frames in a fire rated door assembly need to be identified that they are fire rated frames, but they do not have to be listed with a specific fire rating. NFPA 80 requires the door frame to be labeled as a fire rated frame, but it does not require the hourly rating to be on the label. It is apparent that a label that says it is a fire rated frame (but with no hourly rating) is good for up to and including 3-hour fire rated door assemblies. After that, the hourly rating needs to be inserted on the frame label.

In this situation the surveyor relented and the finding was not included in the survey report. Another example where a tactful approach explaining the codes and standards to the surveyor can lead to a successful outcome.

Tags: ,


Nov 13 2014

Use of Fire and Smoke Doors During a Fire Drill

Category: BlogBKeyes @ 6:00 am
Share

imagesVOC6UHJ4

I was recently asked if the Life Safety Code addresses the use of smoke and fire doors during a fire drill. Here is what I responded with:

The Life Safety Code (LSC) does address certain key actions required by staff during a fire drill, but it does not specifically restrict the use of doors in fire or smoke compartment barriers while the fire alarm is activated. Section 18/19.7.1.1 of the 2000 LSC requires the healthcare occupancy to have a written plan for the protection of all persons in the event of a fire; for the evacuation to areas of refuge; and for the evacuation of the building when necessary. Section 4.7 of the same code also makes similar statements regarding orderly evacuation during a fire drill. It makes sense that opening and closing doors in a fire or smoke compartment barrier would be necessary in order to evacuate patients to another smoke compartment, or to evacuate the building. It also makes sense that responding emergency personnel (both internal and external) would have to open and close doors in order to assist with the evacuation or address the fire.

But perhaps what you are referring to is the action of the people who are not responding to the fire alarm, and they are going about their regular activity. Doctors, nurses, technicians, visitors, volunteers, vendors, and others may be ignoring the fire alarm and just continue to walk through doors to other parts of the building. These may be the people who you are referring to that are opening and closing fire and smoke compartment barriers doors during a fire alarm.

The Joint Commission standard EC.02.03.03, EP 4 says staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan. This is a little bit more than is required by section 18/19.7.1.3 of the 2000 LSC, which says employees of healthcare occupancies shall be instructed in life safety procedures and devices. A fire drill is certainly one method of instruction in life safety procedures and devices. But neither the Joint Commission standards (and EP) and the LSC reference actually requires all staff to participate in every fire drill. It just wouldn’t be practical in a healthcare facility that is providing treatment and care to patients.

Therefore, hospitals get to decide for themselves how their staff should react during a fire alarm, as stipulated in their fire response plan (also known as the Fire Safety Management Plan). Most hospitals that I have had the pleasure of working with require staff in the immediate area of the fire emergency respond by following R.A.C.E. (Rescue; Alarm; Contain; and Evacuate or Extinguish) and staff away from the origin of the alarm simply close doors and be ready to receive patients. Some hospitals have staff away from the origin of the alarm to dispatch one individual with a fire extinguisher to the scene of the alarm.

You can write into your plan what you want your staff to do. If you want them to stop at each closed door and not traverse through it until the ‘all-clear’ is given, that is your decision, but I don’t think that is a very practical idea, or one that would be followed. When a fire alarm is activated, it represents a potential disaster and even though it may seem that a ‘all-hands-on-deck’ call is needed, that is not the practical thing to do as a first response. If your facility has 1200 workers on the average day shift, and the fire alarm is activated in the 4th floor ICU, you do not want all 1200 workers to rush up to the 4th floor ICU; that is not practical.

The concept of fire response in a healthcare occupancy is all healthcare workers are trained in the facility’s fire response plan. You count on the staff in the immediate vicinity of the fire to respond appropriately and quickly. Once the alarm is announced, certain trained individuals rush to the area where the alarm originates. The rest of the staff is supposed to reply in accordance with your fire response plan. Quite honestly, unless the staff has specific duties during a fire alarm, moving about the hospital performing their normal duties in areas away from the alarm would be considered appropriate. You actually need the hospital to continue to function even during a fire drill. Each fire drill will not asses every staff member’s response; it just is not practical in such a large setting. That is one reason why there are so many fire drills in a hospital each year: By sheer quantity you hope to get nearly all of the staff to participate in at least one drill.

Another issue is physicians. What should they do during a fire alarm? Many hospitals are writing into their fire response plan that physicians on a nursing unit that are not actively providing care or treatment to a patient, should report to the nurse’s station and await direction. In a Surgery department, unless the operating room is the scene of the fire, you pretty much want surgeons and nurses to remain in the operating rooms and continue with the business at hand, and wait for further instructions from the surgery nurse’s station.

I don’t know if I’ve helped you with your question, but if it were me, I would let people do what they normally do, unless they have specific responsibilities during a fire alarm. If you are really concerned about certain fire or smoke compartment barrier doors being opened in close proximity to a fire, then it would be practical to station one person at the door preventing unauthorized individuals from opening that door.

Tags: , ,


Aug 24 2012

Free NFPA 80 Webinar

Category: BlogBKeyes @ 4:00 pm
Share

Free Webinar:  NFPA 80, Inspection, Testing, and Maintenance of Swinging Fire Doors

Sponsored by DHI, FDAI, Door Security & Safety Foundation, & Intertek August 28, 12:30 – 2:00 pm EST

Building owners and managers, authorities having jurisdiction, and the fire door inspectors all have important roles and responsibilities in a building’s annual fire door inspection process. This webinar will discuss the current requirements of the 2010 NFPA 80: Standard for Fire Doors and Other Opening Protectives, related to the inspection, testing, and maintenance of fire door assemblies as well as the specific responsibilities of all parties involved in the door inspection process. Some of the changes to the 2013 edition of NFPA 80 will also be highlighted. In addition, common door deficiencies and inspection issues to look for in the field will be shown.

This is a timely offer from NFPA as the 2010 edition of NFPA 80 will be referenced by the new 2012 edition of the Life Safety Code when that is finally adopted by CMS. Be ready for the new testing and inspection requirements for all fire doors by attending this free webinar.

Tags:


Aug 02 2012

Solving Fire Door Penetrations

Category: BlogBKeyes @ 5:00 am
Share

I ran across a vendor called Fire Door Solutions, Inc. (www.firedoorsolutions.com) who has come up with a unique solution for those pesky penetrations in fire rated doors. On older fire doors, it is not uncommon for the facility to replace the automatic closure with a new device, but the mounting hole pattern on the new device does not always line up with the old one. NFPA 80 Standard for Fire Doors and Other Opening Protectives (2010 edition), section 5.2.15.4 permits holes in doors to be filled with a steel bolt, or the same material that the door is made of. I quote the 2010 edition of NFPA 80 as that is the edition that healthcare organization will need to be in compliant with once the new 2012 edition of the Life Safety Code is adopted. Also, the 1999 edition of NFPA 80 does not address repairing holes in fire rated doors.

 

What I commonly see in the healthcare industry as I conduct inspections and surveys, is a maintenance person will take a standard steel bolt, nut and washers and insert them to fill the left-over holes in the door. While this meets the intent of the standard, it leaves a slightly unprofessional look to the door, to say the least. Fire Door Solutions has developed a thru-bolt that has flat heads on both ends, has both male and female threads, and screws into itself. Once installed it leaves a very clean look without the ‘tail end’ of the bolt extending through the door with washers and a nut. (See picture to the left, which is courtesy of Lori Greene)

 

 

 

 

 

 

Another product which Fire Door Solutions developed and markets is a firestop caulk to fill holes in fire rated doors. One might think that they could just use one of the many different firestop caulks available on the market today, and just squirt some of the ‘red stuff’ into the hole, and be good. Well, one would be wrong, as until recently, there was no firestop caulk available on the market with an approved listing from an independent testing laboratory for fire door repairs, according to Fire Door Solutions. They developed this firestop caulk, had it tested by a well-known independent testing laboratory and now have the only listed firestop caulk approved for use to fill holes in fire rated doors, up to 3/4 inch. According to their literature, the thru-bolts and firestop caulk are paint-able. I talked with their VP of Operations recently, and he told me the big problem with standard firestop caulk used to fill  is it would not withstand the hose stream test that NFPA standards require. His new caulk passed those tests without difficulty.

Now, I’m not endorsing these products as I have never used them. But it seems to me that they could serve to solve frequent problems when changing out defective hardware on fire rated doors, rather than tossing the doors away and purchase new ones. Since operation funds are always tight for hospitals and nursing homes, this could go a long way to keep those operating budgets in check.

Tags:


Next Page »