I’m just going to admit it – I’m confused – and I’m hoping that someone who works more closely with the Joint Commission can help to clear this up.  The Joint Commission recently distributed a document giving notice of 3 changes to their standards; 2 of the changes involve doors, and the effective date is March 11, 2018.

The first change affects Section EC.02.03.05 EP25, which addressed fire door inspection.  The change clarifies that non-fire-rated doors, such as corridor doors to patient rooms, are not subject to the annual inspection requirements of NFPA 80 or NFPA 105.  It also says that those doors should be routinely inspected and maintained.  What I’m not clear on is the change that removes the words “written documentation of” (annual inspection and testing of fire door assemblies).  Does this mean that health care facilities are not required to maintain documentation of their annual fire door inspections as required by NFPA 80/105?  UPDATE:  Several readers commented that the documentation is still required because of the D in the circle adjacent to the requirement.  It seems odd and confusing to me that the line was removed from the text, but at least it looks like the annual fire door assembly inspections must still be documented as required by NFPA 80/105.

The other change that addresses doors was made to Section LS.02.01.30 EP13, on the latching of corridor doors in existing health care facilities.  This note was removed by the change: Note: For existing doors, it is acceptable to use a device that keeps the door closed when a force of five pounds is applied to the edge of the door.  The change includes some additional language stating that positive-latching hardware is required for corridor doors in health care facilities (except bathrooms, toilets, and sink closets that do not contain flammable or combustible materials) and that roller latches are prohibited on doors where latching hardware is required.  This requirement has been in place for many years – I wrote about roller latches here, and the 2003 CMS bulletin on roller latches is here.

Two notes were added in the most recent change.  Note 1 says that powered corridor doors must be equipped with positive latching hardware unless the door manufacturer does not provide that option – in that case the door must require at least 5 pounds of force to open.  Note 2 clarifies that bathroom doors, shower rooms, and other rooms without combustible material are not required to have a latch or a device that keeps the door closed against 5 pounds of force.  Since these requirements were already in place, the only change I see is that if an automatic door manufacturer does not have a way to facilitate positive latching, those doors can be kept closed with a device that requires 5 pounds of force to be applied.  What type of “powered corridor doors” do not have the option of positive latching?  Where does this exception apply?

I’d appreciate any insight you can share on these revisions to the Joint Commission standards.  WWYD?


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