Allegion-FDAI-Card-Page-001Last month I wrote an article for Doors & Hardware about the changes that health care facilities should be aware of now that the 2012 edition of NFPA 101 – Life Safety Code has been adopted by CMS – Centers for Medicare / Medicaid Services.  In that article, I mentioned the requirements for annual fire door inspections, which were not a part of the previously-adopted edition of NFPA 101, but are part of the 2012 edition.

Several people asked if I was sure that the inspection requirements would be enforced.  Generally, when a new code is adopted, I don’t question whether a change will be enforced.  For example, when the IBC requirement for panic hardware changed from doors serving Assembly & Educational occupancies with 100 people or more to Assembly & Educational occupancies with 50 people or more, we just started specifying and supplying panic hardware on rooms half the size of the rooms that required panic hardware in the past.  Whether it is specifically enforced or not is irrelevant – if the code requires it, we do it.  Of course, a state or local jurisdiction could modify the model codes and require / allow something different, but whatever the adopted code requires is what should be done.

The reason people are questioning whether annual fire door assembly inspections will be enforced by CMS, the Joint Commission, and other AHJs responsible for health care facilities, is because there has been relatively low enforcement of these inspection requirements for other types of facilities.  Why?  I’m still scratching my head about that one.  Yes – it costs money to have an inspection done, and the inspection could uncover necessary repairs which also cost money.  But the codes and standards have always required fire door assemblies to be kept in code-compliant condition.  Failure to do so could result in fines or increased liability if a fire occurs.

Will fire door inspections be enforced for health care facilities?  NFPA 101-2012 clearly requires them, but it seems that more proof was needed.  So, I asked the Joint Commission, and I was told that as of July 5th, 2016, CMS will require compliance with the 2012 edition of NFPA 101, and because the Joint Commission standards are aligned with CMS, the 2012 edition of NFPA 101 will be utilized – including the requirements for annual fire door inspections. 

This was also stated in an article by Kristin Bigda of NFPA, which appeared in NFPA Journal:

“Healthcare facilities have a lot of doors. Many doors, such as those protecting exit stairs, horizontal exits, and hazardous areas, are required to be fire-protection rated. With the anticipated adoption of the 2012 edition of NFPA 101®, Life Safety Code®, by The Centers for Medicare and Medicaid Services (CMS), many healthcare facilities will have to add fire-protection rated doors to their list of building systems that require periodic inspection and testing.”

I think that should clear it up.  Health care facilities that are subject to the CMS requirements WILL need to conduct fire door inspections annually, document the findings, and make needed repairs “without delay.”  I know that some facilities have been preparing for this and have conducted inspections for several years.  I’d love to hear some stories from the field about how facilities have tackled this.  Are the inspections conducted by a consultant, or in-house staff?  What training program is being utilized?  How are the findings documented?  What are the biggest challenges?


There’s more information about fire doors on the fire door page of this site, including a laminated card that is available free of charge (the front is shown above).  Just email me or ask your local Allegion rep if you’d like some.

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