Fire-Rated Doors

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.

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.