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ASHE reference provides guidance on swinging doors


November 1, 2018

For anyone out there in the hospital safety or engineering world that needs a little help understanding all the codes and regulations regarding egress and fire door issues in healthcare— that pretty much means anyone who works in the healthcare industry, especially those who need to know the Life Safety Code® (LSC) inside and out—ASHE has a new reference book for you.

In many ways, a door is a simple device. It’s considered the entry point into (or exit out of) a room or a building, and we take it for granted because we see doors and use them every day. For many of us, the door can be a focal point, something of aesthetic value that we make into a decorative piece for our home, room, or even office. 

But to those who deal with fire doors in hospitals, doors are lifesaving tools. They require constant attention because their function is very simple: to save lives of those who can’t save themselves by blocking the advance of fire and smoke in the rare event of a fire in a healthcare facility. Fire doors are likely something you think about on a regular, if not daily, basis. And regulators do too. But what they expect from you can be confusing.

For a long time, most hospitals followed standards set forth by The Joint Commission, which also followed standards contained in the 2000 edition of the LSC approved by CMS. That changed when CMS adopted the 2012 edition of the LSC, as had been anticipated. CMS also now requires hospitals to follow the 2010 edition of NFPA 80, known as Standard for Fire Doors and Other Opening Protectives, which requires side-hinged swinging fire doors to be inspected and tested on an annual basis. NFPA 80 is a standard that covers the installation, inspection, testing, and maintenance of several types of fire-door assemblies.

“Perhaps the single most important point to remember regarding performing safety inspections of door assemblies is that most of NFPA 80’s requirements for swinging doors are general,” writes Keith E. Pardoe, FDAI, DAHC, CDC, CDT, president of Pardoe Consulting LLC in Culpeper, Virginia, in the new ASHE reference, Inspecting and Maintaining Swinging Doors: A How-To Guide to Egress and Fire Door Safety.

“By design, 80 relies on the manufacturers’ published listings and installation instructions for many door-assembly components,” he notes. “When the listings or installation instructions for specific door-assembly components are not available or do not include the necessary detail, NFPA 80’s requirements prevail.”

What does this mean to you? Well, for the most part, you’ve been on your own setting your time frames for inspections. As long as the side-hinged swinging fire door assemblies work the way they are supposed to on survey day—which could be anywhere from 18 to 36 months after your last survey—that’s really all you’ve been responsible for from a regulatory standpoint. Now that the 2012 edition of the LSC has been adopted by CMS, you’re going to have to show documentation of an annual inspection program and all the paperwork that goes with it.

That sounds simple, but we all know there’s more to it than that. Fire doors and other swinging doors go through major wear and tear, and they often do not close and latch as they are supposed to. Inevitably, someone will prop open a fire door or store a supply cart in front of an egress door. If an inspector sees these things, it’s an instant citation. The best safety officers know that an ongoing system of inspection is the best way to stay on top of things.

Pardoe’s book is pretty much an almanac of swinging doors, and his guidance can help even the most amateur of safety professionals. The book starts with a primer on the different types of swinging doors that a hospital will have installed, and why proper installation is so important to avoid headaches later.

“Because these types of doors are component-based, the door frame and door leaf might be products of the same or different manufacturers,” he writes. “Hinges and other door hardware can be products of various manufacturers. All these components are assembled at the door opening to create swinging-door assemblies. Another thing most swinging doors have in common is the process in which they are installed. Door frames are installed first, followed by attaching the door leaves to the frames with hinges or pivots. Latching, controlling, and protective hardware components are the last products to be installed. Of these steps, door-frame installation is the single most important step in the process. Improperly installed door frames create operational and noncompliance issues that can be difficult to correct without removing and reinstalling them.”

This is especially important on new construction projects, Pardoe writes, as door frames for installation in masonry walls are delivered early in the project. Masons erect and set these door frames in place before the walls are laid up. A misstep during the frame installation at this stage might not be discovered until much later when the door leaves and hardware are installed, and that can mean costly repairs, interruptions to your hospital’s daily operations, and even citations from surveyors if your swinging doors don’t close properly.

Who you choose to install these doors is very important, he adds. Interestingly, despite the critical nature of these doors, no formal door installation training or certification is required.

“Consequently, the operation and function of swinging doors are subject to the competencies of the installers,” Pardoe writes. “Malfunctioning and noncompliant swinging doors cannot be expected to perform reliably as required by the codes or as tested by the manufacturer.”

To combat this, he says you may want to go the way of swinging door assemblies (e.g., aluminum doors and frames) that are installed by the door and frame supplier (using the supplier’s trained and experienced personnel), which reduces many of the operational and functional problems caused by poor installation. Also, door installation contractors have skilled personnel who install many different types of door assemblies.

“Some types of swinging-door assemblies are unit-based systems, meaning that the door frame, door leaf, glass and glazing and hinges/pivots (and sometimes more hardware) are produced and packaged together as units. These doors are installed by factory-trained personnel, greatly reducing problems arising from poor installation practices,” Pardoe writes.

Inspection guidelines

According to Pardoe, codes do not require elements such as swinging-door assemblies to be perpetually updated as changes are made in the codes. That’s good news for you, as to do so would place an undue burden on owners that would not be feasible to sustain for the life of the building. The doors were designed to meet the code requirements that were in effect at the time of construction. That fact alone will save you money and hardship.

Basically, if you are maintaining a well-documented, annual door inspection with records and maintenance schedules that you can show to inspectors, you’re well on your way to being compliant. However, Pardoe notes that there are a few things you should be aware of:

The fire rating of the entire swinging-door assembly is only considered to be valid when all its individual components are installed and the assembly functions as required by the codes. When non-fire-rated components are installed on the assembly or the door does not operate correctly for any reason, the fire rating of the assembly is considered invalid and therefore noncompliant.

Some door-assembly inspectors and authorities having jurisdiction might not be aware of the subtleties of code requirements for existing doors. At times, they might apply today’s code requirements to yesterday’s doors, which is not necessary in most cases. Owners might unknowingly spend resources upgrading their doors when it is not required by the codes.

Know how to look up your codes, and look in several places. Interpreting and applying code requirements takes time, practice, and a fair amount of patience, especially pertaining to swinging doors. Many times, subtle distinctions in the codes help to determine the correct way to resolve a situation, but several references may need to be searched for a correct answer.

How to keep your doors well-maintained

Here are a few tips to follow to ensure your doors are in good shape:

Exceed what the standards require. Make your own standards (sort of). The most recent standards out there are from NFPA, who say they want you to inspect annually. But there’s nothing keeping you from establishing a monthly inspection program. Not only will that keep you ahead of any problems, it will also impress the inspectors.

Make sure hardware works the way it was intended. This means actually testing the doors. The best safety officers walk through their facilities, open and close their doors, and make sure the doors close and latch when the fire alarm is tested.

Don’t forget rarely used doors. Make sure you are checking doors that aren’t used much, such as those that lead to rarely used suites and exterior doors. You want to ensure your exit doors are opening and closing. Some doors that are rarely used but are technically a route of egress could be subject to a citation if they don’t work on survey day. Just because they’re not used often doesn’t mean they won’t ever be used.

Train staff. It’s important to train staff on the importance of a properly working fire door. All staff (nursing, etc.) should be on the lookout for non-functioning fire doors because you can’t rely strictly on the facilities staff to identify a particular issue during their inspections. If someone sees a broken door, that person needs to call in a work order.

Use the data you collect. Having the doors inspected is the minimum requirement of complying with the standard; using that information and data to your advantage is a step further. Once your facility’s baseline of inspection results is determined, it is important to step back and analyze where those “problem doors” are. This will allow for more effective, more timely inspections.

Talk to your carpenters. Before you or anyone else make changes to any doors, make sure you know if the changes could compromise the door’s ability to serve as a fire barrier.

Pass ownership to those who break the doors. If environmental services keeps hitting the doors with carts and making them break, take the repair money out of their budget—you might find that the issue suddenly resolves itself.

Inventory problem doors. You should be utilizing a system to keep track of the doors that keep giving you problems. Computerized maintenance management software is available for this purpose. It can help you keep track of what to look for during door inspections. Having the checklist also allows “failure modes” for the doors to be fed into the dashboards/metrics so common causes of failures (latching issues, broken closer, etc.) can be monitored.

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