Q: Now that we have some clarification from CMS on annual door inspection [See CMS S&C memo 17-38, dated July 28, 2017], I wanted to see if there was any new interpretation on rated corridor doors (20 minute and up) that are installed in non-rated wall assemblies. In looking at most publications from different authorities, they have interpreted that all rated doors need to be annually inspected since it could be obvious to the public. Section 184.108.40.206 of the 2012 Life Safety Code says existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. However, section 220.127.116.11 says where specific requirements contained in Chapters 11 through 43 differ from general requirements contained in Chapters 1 through 4, and Chapters 6 through 10, the requirements of Chapters 11 through 43 shall govern. If the chapters 11-43 govern over chapters 1-10 why are the authorities not recognizing 18.104.22.168.3 where it states compliance with NFPA 80 shall not be required? Unfortunately, it doesn’t say this for “smoke barrier” doors, so the authority’s logic could still have reason. In my interpretation of 22.214.171.124 and reading the appendix it seems that NFPA is referring to first response Life Safety features, like a pull station, fire extinguisher, strobe lights, fire panels etc….. If Joe Public is seeing a fire door do its thing, it’s probably too late. Certainly, first response LS features should always work even if they are not required.
A: You make many excellent points. But the way I see it (and interpretations by most of the AOs and CMS agree), section 126.96.36.199 of the 2012 LSC requires compliance with NFPA 80 for fire doors and windows. There are no exceptions in 188.8.131.52 that exclude fire-rated doors located in non-fire-rated barriers. Compliance with 184.108.40.206 is required by section 220.127.116.11.1.1. Where section 18.104.22.168.3 says compliance with NFPA 80 is not required, they are speaking about non-fire-rated corridor doors, which are in smoke partitions that separate a corridor from another area or room.
Smoke barrier doors are often not corridor doors; they are cross-corridor doors. But at times, a smoke barrier can (and does) include a corridor wall and what appears to be a corridor door is now also a smoke barrier door. In those situations, the hospital has to comply with the most restrictive requirements.
To me, it is plain: If you have a fire-rated door (regardless if it is located in a fire-rated barrier or not), then it must comply with NFPA 80 and you must test and inspect it on an annual basis. I’ve been told that the opinions from the staff at NFPA do not agree with this, but NFPA does not enforce the LSC, so we need to comply with those interpretations made by the authorities who enforce the Life Safety Code, such as CMS and the AOs.