Roller Latches

Roller latches…. Many of us already know that the Centers for Medicare & Medicaid Services (CMS) banned the use of roller latches in hospitals by March 13, 2006. So that would mean roller latches are not permitted anywhere in the hospital, right?

Well, that is not the entire truth. Actually, there are situations where roller latches are permitted in hospitals, and still comply with the CMS directive. If a door is equipped with roller latches and the door is an interior door inside a suite-of-rooms, and the door does not serve a fire rated opening (such as an exit stairwell, or hazardous room), then the door may have roller latches, since the door is not required to close and latch. Actually, there are no requirements for doors inside a suite of rooms (other than exits and hazardous rooms) so logically speaking, if there are doors, then they are not required to close and latch.

So now you may be thinking outside of a suite-of-rooms, roller latches would not be permitted, right? Well, actually, there is one more situation where roller latches would be permitted. Take a look at section 19.3.6.3.2 in the 2000 edition of the LSC. This is the section that describes how a corridor door should be provided with a means to keep the door closed. Exception #1 allows doors to toilet rooms, bathrooms, shower rooms, and sink closets where combustibles are not stored to be exempt from the need to have a device to keep the door closed. Therefore, if these doors are not required to have a latching device, then roller latches would be permitted in this situation.

The reason why CMS banned roller latches from doors that are required to be kept closed (such as corridor doors) is the result of investigations of fires in hospitals. It is documented that many lives have been lost where hospital patients could not get up and walk out under their own power during a fire emergency, and they lay in bed and died from smoke inhalation. The doors to patient rooms were commonly provided with roller latches so staff could walk-in hands-free, without having to turn or twist a door knob. However, during a fire, the heat build-up in the corridor created pressure which over-came the latching force of a roller latch and the patient room doors popped open, allowing smoke to enter the room.

It probably is a good idea to eliminate all roller latches in your facility, but if you have roller latches in one of these two situations and a surveyor or inspector catches it, you might be able to explain away a citation if the door in question is not required to latch.

 

Adding Windows to Fire Rated Doors

Q: I have a supply room on a medical surgical floor and the door opens into the corridor.  The corridor and the room are protected with automatic sprinklers.  Because it is a supply room we are using a ¾ hour door.  We would like to allow light to enter the room from the corridor and wanted to install a window in the door.  Are we allowed to do this and are we limited in the size of the window?

A: Since you said the door is ¾ hour fire rated, then section 8.2.3.2.1 of the LSC requires compliance with NFPA 80, Standard for Fire Doors and Fire Windows (1999 edition). NFPA 80, section 1-3.4 requires any modifications on fire rated doors to be performed in facilities that are licensed by the door manufacturer. The manufacturer is the entity with the responsibility of ensuring the integrity and fire rating of the door and any modifications to their specifications would jeopardize that rating. Therefore, the standard does not allow any field modifications to a fire rated door, other than those required to install already approved fire rated hardware, such as door closures, latch-sets and hinges. So, the answer to your question is yes, a window would be permitted to be installed in a fire rated door, but the door would have to be removed and sent back to an approved licensed facility were the modification could be made. As you can imagine, this is not a simple or inexpensive proposition, and is not done very often. If the supply room is not required to have 1-hour fire rated walls, then it may be more cost effective to replace this door with a non-rated, smoke resistant door with a window already installed.

Door Clearance

Q: We recently failed a licensing inspection because the gap at the bottom of the door exceeded 1/8″. The inspector stated “no gap between surfaces greater than one-eighth of an inch is allowed at door and door heads and jambs” . I have researched the NFPA 101 Life Safety Code manual and can not find this stated any where. Can you provide any direction or reference? Thanks

A: Your question did not differentiate between a non-rated corridor door, a smoke compartment door, or a fire-rated door, so I will cover all issues. The NFPA 101 Life Safety Code (LSC, 2000 edition) discusses door gaps and undercuts in a couple various locations:

Non-Rated Corridor Doors

Section 19.3.6.3.1 requires the clearance between the bottom of the door and the floor covering (which is also described as ‘undercut’) to be no more than 1 inch on non-rated corridor doors. This section states that compliance with NFPA 80 is not required, so the gaps on the vertical edges of a non-rated corridor door and the door frame is not regulated, other than the door has to resist the passage of smoke. If this facility is inspected by Joint Commission or CMS, then take a look at the attached CMS S&C Letter 07-18 on door gaps for corridor doors. It allows a gap up to ¼ inch between the door and the frame in non-sprinklers compartments and a gap up to ½ inch between the door and the frame in sprinklered compartments. There are a few exceptions to the above requirements, involving corridor doors to toilet rooms, shower rooms, and sink closets, provide they do not contain any combustibles.

Smoke Compartment Barrier Doors

Section 19.3.7.6 requires doors in the smoke compartment barrier to meet the requirements of 8.3.4, but it also says the door does not have to positively latch. The Annex section for 8.3.4.1 refers to NFPA 105 for guidance, but this is not part of the enforceable section of the LSC. NFPA 105 says doors used in a smoke compartment must meet NFPA 80 requirements, but again, this is not made mandatory by the LSC. But NFPA 105 does require the gap between a smoke compartment door and it’s frame to be no more than 1/8 inch.

So, here is my conclusion: Since there is no other reference in the LSC about smoke compartment doors and the gap between the edge of the door and the frame, then I believe most authorities having jurisdiction (AHJ) will stay with the recommendations found in NFPA 105, which is not to exceed 1/8 inch. Likewise, for the door undercut, they will most likely stick with ¾ inch, which is found in NFPA 80.

Fire Rated Doors

Section 8.2.3.2.1 requires door openings in fire rated barriers to meet the requirements of NFPA 80 (1999 edition). Section 1-11.4 of NFPA 80 refers to Table 1-11.4 which requires the clearance between the bottom of the fire rated door and the floor (undercut) where no sill exits to be no more than ¾ inch. The undercut is limited to 5/8 inch where rigid floor tile is used, and the undercut is limited to ½ inch where floor coverings are used. The undercut to a raised non-combustible sill is 3/8 inch. The clearance between the sides of the fire rated door and the frame is limited to 1/8 inch ( plus or minus 1/16 inch) for steel doors, and must not exceed 1/8 inch for wood doors, according to section 2-3.1.7 of NFPA 80 (1999 edition).

So, depending on what door the inspector was looking at, he could be correct.

Door Frame Labels

Q: We recently did a survey on our fire rated doors and found many of the frames on the doors had issues with the labels. Some of the door labels were painted, some of the labels did not contain an hourly designation and some frames did not have labels at all. What actions, if any, do you suggest we take in regards to these door frames?

A: Section 8.2.3.2 of the 2000 edition of the Life Safety Code (LSC) requires fire rated door assemblies to meet the requirements of NFPA 80 (1999 edition). NFPA 80, section 1-6.1 states only labeled fire doors can be used, and section 1-5.1 requires the label to be readily visible and convenient for identification by the AHJ. The fire rated door and frame, along with the hardware for the door, is an assembly that must be listed by an independent testing agency, such as Underwriters Laboratory (UL), and when approved, the door and frame must have labels that indicates they have met the requirements for a fire rated assembly. The fire rated door assemblies then must be installed according to the manufacturer’s instructions, and the labels on the doors and frames are required to be readable. UL has said that it is permissible to paint over an embossed label as long as the information on the label is still readable. However, if the label is painted in such a way that the label cannot be read, then the paint needs to be removed, or the door and frame are no longer considered to meet the requirements of a listed fire door assembly. According to the UL Certifications Directory, there is no hourly rating for basic fire door frames, unless the label on the frame states it is rated for something less than 3 hours. The key point is the frame must still have a label indicating it is fire rated. It would be typically acceptable for up to 3 hours but the rating on the assembly is limited to the lowest-rated component. So if the frame is good for 3 hours but the fire door is rated for 90 minutes, then it is a 90 minute assembly. If there’s no label at all, or the label is illegible, the frame can be evaluated and possibly re-labeled in the field. There are approved agencies that will perform this work in the field, and here are a couple links to consider: www.ul.com/fieldinspections and www.intertek.com and type in the search engine “field labeling of fire doors”.

Door Hold-Open Devices Not Connected to the Fire Alarm System

Q: Can a door that opens onto the corridor have a magnet hold-open device that is not connected to the building fire alarm system, and does not release when the fire alarm is activated? The door in question is to an office in a hospital on a nursing unit.

A: The answer is “It Depends…” as there are a few variables here. Yes, a magnetic catch that is not self-releasing during a fire alarm is permitted on corridor doors, provided the corridor wall where the door is located, is not also doubling as a smoke compartment barrier. According to 19.3.6.3.3 of the 2000 edition of the NFPA 101 Life Safety Code (LSC), a hold-open device that releases when the door is pushed or pulled is permitted. The Annex section of 19.3.6.3.3. describes a magnetic catch as a permissible device in this situation. However, as mentioned, this type of device is not allowed on a door in a smoke compartment barrier, nor is it allowed on a door to an entrance to a hazardous room, a stairwell door, or any other door that is required to self-close. These doors are required to self-close when the fire alarm system is activated, so a magnetic catch that is not connected to the fire alarm system would not be permitted.

Adding Windows to Fire Rated Doors

Q: I have a supply room on a medical surgical floor and the door opens into the corridor.  The corridor and the room are protected with automatic sprinklers.  Because it is a supply rom we are using a 3/4 hr door.  We would like to allow light to enter the room from the corridor and wanted to install a window in the door.  Are we allowed to do this and are we limited to the size of the window?

A: Since you said the door is ¾ hour fire rated, then section 8.2.3.2.1 of the LSC requires compliance with NFPA 80, Standard for Fire Doors and Fire Windows (1999 edition). NFPA 80, section 1-3.4 requires any modifications on fire rated doors to be performed in facilities that are licensed by the door manufacturer. The manufacturer is the entity with the responsibility of ensuring the integrity and fire rating of the door and any modifications to their specifications would jeopardize that rating. Therefore, the standard does not allow any field modifications to a fire rated door, other than those required to install already approved fire rated hardware, such as door closures, latch-sets and hinges. So, the answer to your question is yes, a window would be permitted to be installed in a fire rated door, but the door would have to be removed and sent back to an approved licensed facility were the modification could be made. However, as you could imagine, this is not a simple or inexpensive proposition, and is not done very often.

Magnetic Latches on Suites

Q: We recently had an inspection in our hospital where the inspector cited us for our suite doors not having positive latching. The suite doors have 1500 pound access-control magnets controlled by card-swipe badge readers and with wall-mounted push buttons. They are on emergency power and eight-hour battery back-up. They are also approved by our local and state fire marshals. Is the inspector correct, or do I have a case for an appeal?

A: The concept of a Suite-Of-Rooms requires the barriers of the suite to be protected in the same manner as any other room bordering on an exit access corridor. Therefore, entrance doors to the suite must meet the requirements of corridor doors. In your question, you did not specify if your organization is considered a new healthcare occupancy or an existing healthcare occupancy. This is an important issue, as there are different requirements for each. If your facility’s construction documents were approved by the local authorities after March 1, 2003, then it is considered a new healthcare occupancy.

In new healthcare occupancy, section 18.3.6.3.2 of the 2000 edition of the Life Safety Code specifically requires positive latching hardware for corridor doors. The definition of positive latching is a spring-loaded throw on the edge of the door to engage in the strike plate of the door frame. Magnetic locks do not qualify as positive latching hardware. Therefore, you may not use magnetic locks in new healthcare occupancies for suites (corridor doors).

However, for existing healthcare occupancies, section 19.3.6.3.2 of the same Code specifically allows a device capable of keeping the door fully closed with a minimum force of 5 foot-lbs. Some authorities having jurisdiction (AHJ) approve of magnetic locks for this purpose as long as power to the locks is NOT interrupted during a fire alarm signal. Doors in the path of egress are not permitted to be locked except where the clinical need of the patient requires it. Not all AHJs agree on what types of patients qualify for this exception. When locks are permitted on egress doors, they must meet the requirements found in 19.2.2.2.4. The entrance door to a suite-of-rooms is permitted to be locked, as the path of egress is not allowed into and through a suite.

Magnetic locks in lieu of positive latching on corridor doors is not recommended as there are many complications and challenges in compliance, and not all of the AHJs agree on this application. It appears that a successful appeal on this issue would be difficult.

Door swing in direction of egress?

Q: As we work through deficiencies that were found by a consultant, there is one question we need to have clarified regarding doors. The reference to the deficiency is LSC 7.2.1.4 (2000 edition) citing the deficiency as the door swing makes exiting impossible in both directions. We understood that the doors did not need to swing in opposing directions if they are on existing doors. We understood if new doors are being installed they need to be in opposing directions. What is your take on this item in the LSC?

A: I’m not sure I agree with you. It all depends on the use of the door. Is it a door to a stairwell? Or a horizontal exit? Or a smoke compartment barrier? Your question does not make it clear what purpose the door serves, so let’s look at all of the possibilities.

We start with Chapter 19 for existing conditions in the LSC. Look at 19.2.1 where it says every aisle, passageway, corridor, etc. must comply with Chapter 7, except where modified in sections 19.2.2 through 19.2.11. The modifications found in section 19.2.2.5.3 say a door in a horizontal exit does not have to swing with the direction of egress. Also, section 19.3.7.6 says doors in a smoke compartment barrier do not have to swing in the direction of egress. So that pretty much wraps up the exceptions to Chapter 19.

Let’s look at Chapter 7 for door swing requirements:
• 7.2.1.4.2 says side-swinging doors must swing in the path of egress when the room or area served by the door has an occupant load of 50 or more people
• 7.2.1.4.3 says doors shall swing in the direction of egress when used in an exit enclosure (stairwell) or when serving a high hazard area (not very likely in a hospital)
• Chapter 19 provides exceptions for horizontal exits and existing smoke compartment doors, as described above

So what does your door serve?

A stairwell? Then it DOES have to swing in the direction of egress.

A room with an occupant load of 50 or more? Then it DOES have to swing in the direction of egress.

A smoke compartment barrier? Then it DOES NOT have to swing in the direction of egress, as long as it qualifies as an existing condition.

A horizontal exit? Then it DOES NOT have to swing in the direction of egress as long as it qualifies as an existing condition.

A hazardous room (not a high hazard room)? Then it DOES NOT have to swing in the direction of egress.

Note: Existing conditions are defined as those conditions which were approved for construction prior to March 1, 2003.

Door Holder for Isolation Supplies

Q: We are considering the use of storage devices that hook over the top of the patient room corridor doors that will store supplies that we use for contact precautions. Nurses will then be able to access isolation supplies before they enter the room. Are you aware of any reason why these devices could not be used in a hospital?

A: Yes, there may be a few reasons not to use these devices. Will the storage device protrude more than 6 inches into the corridor when mounted on the door? If so, then it would not be permitted. Will the device damage the corridor doors and render them unable to close completely? If so, they would not be permitted. Joint Commission and CMS will permit the use of carts in the corridor to store isolation supplies, as long as the cart is serving a patient who is actively on contact precautions. Typically these carts will hold more supplies than the door storage devices. I know some state health departments will not allow carts in corridors for isolation supplies regardless what Joint Commission or CMS says, so the door storage devices may be the only solution for you.  However, if your state does not have any such limitations, then I suggest you stick with the carts. Damage to the doors and any interference the storage devices would have on the corridor door closing properly would be a great concern of mine.

Laboratory Entrance Doors

Q: We had a mock survey recently and the life safety surveyor indicated that the lab — because it is a hazard area — is required to have all the doors closed to corridors. He said approved hold-open devices don’t count. But we use approved hold-open devices on some of our lab doors. If we are sprinklered and we have door hold-open devices, are we are good to go?

A: Laboratories are required to be treated as hazardous areas if they contain flammable materials in quantities less than what would be considered a severe hazard (NFPA 101-2000 19.3.2.1 LSC). If the lab contains flammable materials in quantities considered to be a sever hazard, then they still need to be treated as hazardous rooms with fire rated walls (per NFPA 99). Any way you look at it, the door to the lab is required to have a closure and positive latching as a hazardous room door.

Section 19.2.2.2.6 permits any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure to be held open by an automatic releasing device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system in your building must be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. This means if you have approved hold-open devices that are connected to the fire alarm system on the lab doors, and they release the door when the fire alarm system is activated, then you qualify to have these devices. The fact that your facility is sprinklered does not have any bearing on this subject.

It appears to me that your scenario of approved hold-open devices connected to the fire alarm system meets the requirements of Life Safety Code.