Fire Rated Door Assembly

Q: We are planning to install double egress doors within the corridor for the purpose of separating the clean OR area from the dirty side. The doors and frame that were ordered happen to be rated for 45-minutes. This will not be a smoke or fire barrier and the doors/frame will only extend up to the drop ceiling. Since the doors are rated for 45 minutes, do we need to maintain these doors as fire rated doors and inspect them on an annual basis?

A: Yes, you do. Section of the 2012 Life Safety Code says existing life safety features obvious to the public, if not required by the Life Safety Code, shall be ether maintained or removed. A door and frame that are labeled that identifies the door assembly as a fire-rated door assembly is interpreted by CMS and the AOs as being “obvious to the public”. Therefore, a fire rated door assembly that is not located in a fire-barrier (as you described) would have to be maintained as such and be tested and inspected on an annual basis, because the label is ‘obvious to the public’.

However, if the label is not obvious to the public (meaning it is on top of the door) then it would not have to be maintained as a fire-rated door assembly. Also, if you wanted to delete this door from the list of fire-rated doors that are tested and inspected on an annual basis, then you may remove the fire-rated label and it is no longer obvious to the public.

I’ve been told by reliable individuals that NFPA does not believe that a fire-rated label is obvious to the public, and I would not disagree with them. But they are not the AHJs. CMS and the AOs are AHJs, and the informal interpretations from them says the label is obvious to the public.

If you don’t want to test the door every year, take the label off. But be advised, you can never place that label back on if you change your mind. You would have to have it re-inspected by a UL listed company who inspects doors for re-labeling.


Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.