It’s hard to believe that it has been almost two years since I wrote about the Joint Commission’s position that fire door assemblies in health care must match what is required for the location where they are installed.  Their view was that a fire door assembly could not have a higher rating than what was needed for the wall where the assembly was located, and that a fire door assembly could not be installed in a location where a fire door assembly was not required.

When I discussed this with NFPA staff, their opinion was that NFPA 101 does not prohibit fire door assemblies from being installed where they are not required, and that the required ratings stated in the code are a minimum requirement; a higher rating is acceptable.  I have never received further clarification from CMS on this issue, but it hasn’t come up much lately.  I don’t know if it is being enforced by the Joint Commission – if you know…tell us!

It is not uncommon for a door and/or frame with a fire label to be installed where a fire door assembly is not required.  Although this could cause some confusion when it’s time for a fire door inspection, I don’t see a major life-safety problem with this practice.  It doesn’t seem plausible to me that a building occupant would see a 90-minute label on a fire door and assume that they will be protected for 90 minutes (even if the wall doesn’t offer this level of protection).  Reading the fine print on a fire door label and making life safety decisions based on that is much less likely than a building occupant seeing sprinkler heads and assuming that there is an automatic fire sprinkler system in the building.  (Note: This is my opinion and I am not an AHJ.)

If an AHJ does enforce this requirement and order unnecessary fire door labels to be addressed, what’s the proper protocol?  One company introduced decommissioning labels, and began offering a service to decommission fire door assemblies and install the labels.  However, the Office of the State Fire Marshal in Kansas (where the company is located) issued a bulletin stating that this practice is unacceptable.  It’s best to check with the local AHJ before embarking on a course of action.

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