Fire Door Inspection Requirements In Healthcare Facilities - LSS ®

I’m sure by now everyone is well aware that The Centers for Medicare & Medicaid Services (CMS) has issued a memorandum on required annual fire door inspections in healthcare facilities. This memo stated that the deadline for compliance with The National Fire Protection Association’s (NFPA) requirements for annual fire door inspections had been extended to January 1, 2018. And now that it is the middle of September,  time is running out!

NFPA 80, Section 5.2.1 requires, “fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ”.

Making sure that your facility’s fire doors are tested and inspected annually and providing a written record for your AHJ may seem like a tedious task. But a properly functioning fire door is critical to the integrity of the building and the safety of its occupants. Fire doors are designed to prevent the passage of fire and smoke, while providing a safe evacuation for patients, resident, doctors, nurses and anyone else who maybe in the building during a fire. There are many parts that go into making a fire door work, which make inspections complex and require a qualified inspector in the field to perform the annual inspection as accurately as NFPA requires.

According to NFPA 80, Section 5.2.4.2, “As a minimum, the following items shall be verified:”

1. No open holes or breaks exist in surfaces of either the door or frame.
2. Glazing, vision light frames & glazing beads are intact and securely fastened in place, if so equipped.
3. The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
4. No parts are missing or broken.
5. Door clearances at the door edge of the door frame, on the pull side of the door, do not exceed clearances listed in 4.8.4 (the clearance under the bottom of the door shall be a maximum of 3/4″) and 6.3.1 (top & edges 1/8″).
6. The self‐closing device is operational; that is, the active door completely closes when operated from the full open position.
7. If a coordinator is installed, the inactive leaf closes before the active leaf.
8. Latching hardware operates and secures the door when it is in the closed position.
9. Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
10. No field modifications to the door assembly have been performed that void the label.
11. Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

That’s a lot to inspect and maintain on a fire door! But in order for the door to properly do its job, all of the items above should be inspected and repaired. If your fire doors are not being tested and inspected every year, as required NFPA, they may be out of compliance and can potentially put lives at risk. Don’t wait for it to be too late, ensure your facility’s fire doors are properly working by having them inspected and repaired.