Recently, (within the past few years) The Joint Commission has begun enforcing an NFPA 80 2010 edition, code requirement which mandates that fire doors have an annual inspection. This brought quite a bit of initial confusion to the healthcare industry, which created quite a bit of opportunity for vendors, consultants and others to benefit handsomely. Inspecting doors that weren’t required to be inspected, replacing doors that didn’t need to be replaced and modifying doors and frames that didn’t require modification all led to the expenditure of millions of dollars needlessly. Consider the fact that replacement of a single fire door and frame can easily cost $6,000 – $8,000 and you quickly see how costly this can be, since a 200 bed hospital could easily have well over 100 fire rated doors locations in it. Now that the smoke has settled, let’s look at what’s left and what the requirements actually are.
Not all doors in a healthcare facility require annual inspections. According to NFPA 80 2010, and the other relevant regulatory bodies (ie., CMS, The Joint Commission, DNV, and HFAP) this requirement is only relevant to rated fire doors covered by NFPA 80. Smoke doors (unless serving as combination fire and smoke doors), patient room doors, office doors, etc. would not require this inspection. Wood and metal rated fire doors in single or pairs would require such an inspection. In addition, rated access panels for shafts, dumbwaiter doors, linen and trash chute doors and other fire rated elevator doors would require inspection. The standard requires that these fire doors be inspected at least annually, which according to current TJC standards is 12 months from the date of last inspection plus or minus 30 days.
The individuals who inspect these doors should be qualified by education and experience. Typically, trained fire door technicians from vendors, in house staff who have participated in formal training programs for organizations like NFPA, fire door manufacturers, and recognized testing laboratories, etc., are considered as being qualified.
Door inspection requirements include looking at the doors themselves, closers, latches, frames, vision panels, gaps and undercuts, hinges and numerous other items on both sides of the door. Successful completion of a fire door inspection can be completed through the use of any number of standardized forms as long as the form ensures the inspector evaluate all of the relevant components. A sample SMS Inc., form is attached herewith.
Once the fire door assessment has been completed by the qualified inspector, he or she should document these deficiencies on the selected form. In doing so, the inspector must determine for each issue found, whether or not the degree of defect or damage found will adversely affect the ability of the fire door to perform as intended. In the cases of things like a broken or missing latch, a delaminating door, improper field modification of doors with items and materials such as unapproved kick plates or screws into doors and frames, mounting of non-listed items, a missing screw from a hinge, etc., the answer is obviously yes, and the door should be cited as deficient, assigned for corrective action and monitored through completion. Where damage and potential effect are less obvious like minor nicks and scrapes on the door and frame, and small bends on door edges, the inspectors’ judgement must come into play and he or she will decide if the item warrants citation. If not, no further action is required.