Incorrect Interpretations on Smoke Door and Fire Door Testing

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 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 says when specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the occupancy chapter shall govern. Section says doors in smoke barriers shall comply with section 8.5.4. Section says where required by chapters 11 -43 doors in smoke barriers that are required to be smoke leakaged-rated, must comply with section (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 must be tested, even if they are not fire-rated doors. This also is incorrect. The doors identified in 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

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 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

New Fire Door Inspection Requirements

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.

Fire and Smoke Door Clearances

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 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.

Temporary Signs on Fire Doors

Q: Are hand-made temporary directional signs permitted to be taped to fire doors? We had a surveyor tell us that nothing can be taped to a fire door.

A: Yes, temporary signs are permitted to be taped to a fire door, but they are limited in size. NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition, section 1-3.5, says informational signs installed on the surface of fire doors are permitted. The total area of the attached signs is not to exceed 5 percent of the area of the face of the fire door to which they are attached. Signs are required to be attached to fire doors using an adhesive. Mechanical attachments such as screws or nails are not permitted. Signs are not to be installed on glazing material in fire doors, and signs are not to be installed on the surface of fire doors so as to impair or otherwise interfere with the proper operation of the fire door. With a fire door size of 80” x 32” (approximate guess of the fire door in question), a single 8½ x 11 sheet of paper is well below the 5 percent maximum which the code permits. You state that the paper sign was observed to be attached to the door with adhesive, so it appears it meets the requirements for signage on fire doors. Sounds like a case for an appeal or clarification.     

Force to Open a Fire Door

Q: What is the permitted force to open a fire door? What kind of means can be used to test this onsite?

A: The answer to your question is found in section of the 2000 edition of the Life Safety code, which says: “The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf to release the latch, 30 lbf to set the door in motion, and 15 lbf to open the door to the minimum required width. Opening forces for interior side-hinged or pivot-swinging doors without closers shall not exceed 5 lbf. These forces shall be applied at the latch stile. Exception #1: The opening force for existing doors in existing buildings shall not exceed 50 lbf applied to the latch side. Exception #2: The opening forces for horizontal sliding doors shall be as provided in Chapters 22 and 23. Exception #3: The opening forces for power-operated doors shall be a provided in” I am not an expert in the available tools to measure lbs. of force, but a good-old fashion fish scale should do the job. Since you asked specifically for fire doors, I looked at NFPA 80 but did not find anything that would contradict the above section.

Frames for Fire Rated Door Assemblies

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.

Use of Fire and Smoke Doors During a Fire Drill


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/ 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/ 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.

Free NFPA 80 Webinar

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.

Solving Fire Door Penetrations

I ran across a vendor called Fire Door Solutions, Inc. ( 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 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.

Door Closing Speed

Here’s another interesting compliance issue that hospital facility managers will soon have to deal with…. door closing speed on doors mounted with automatic closing devices (doors closures).

Currently, the 2000 edition of the NFPA 101 Life Safety Code (LSC) does not address the speed in which an automatic door closing device actually closes the door. But when the new 2012 edition of the LSC is adopted, that changes. Section (6) says:

“Door closures are adjusted properly to control the closing speed of door leaves in accordance with accessibility requirements.”

The Americans with Disability Act (ADA) guideline 4.13.10 of 1991 says the following about door closing speed:

“If a door is equipped with an automatic closing device (door closure), then the sweep range of the closure must be adjusted so that from an open position of 70 degrees, the door will take at least 3 seconds to move to a point 3 inches from the latch, measured to the leading edge of the door.”

You might say that this ADA requirement has been in effect for decades and you’d be correct. But for the most part, ADA requirements/guidelines are not enforced in an existing occupancy. Once the facility has passed its final occupancy permit inspection, ADA is rarely taken into consideration. This is simply due to the fact that there are few (or no) inspectors using the ADA guidelines as their standard. Now, that changes, at least for the door closing speed, as the LSC has finally referenced that specific issue into their code, which will be enforced by multiple AHJs.

Ironically, the LSC is still silent on the maximum amount of time required to close a swinging door equipped with an automatic closing device.