This post was published in Doors & Hardware
Past fires in hospitals and nursing homes – and the resulting fatalities – have shaped the codes that we use today. While the code requirements for health care facilities go far beyond the doors, frames, and hardware, there are some important considerations for door openings to ensure that they provide the necessary fire protection, egress, and accessibility for residents and staff. Although today’s codes do not typically require corridor doors such as those leading to patient room doors to be fire door assemblies, these doors provide a critical layer of protection for patients.
NFPA 101 – The Life Safety Code
Although NFPA 101 – Life Safety Code states that most corridor doors in a health care facility, including patient room doors, are not required to comply with NFPA 80 – Standard for Fire Doors and Other Opening Protectives, the code does include some requirements designed to help keep patients safe. Doors must be constructed to resist the passage of smoke, and the clearance between the bottom of the door and the floor covering must be no more than 1 inch.* For existing facilities, either 1 ¾-inch solid bonded-core wood doors, or materials that resist fire for at least 20 minutes, are required.
Positive latching hardware is mandated by the code for corridor doors whether they are fire-rated or not, so doors are self-latching when they are closed and will remain latched against the pressure created during a fire. Pairs of doors with an inactive leaf are required to have automatic flush bolts. Louvers, also called transfer grilles, are not allowed in these doors. Protection plates are permitted, whether factory or field-applied, with no limit in size and no requirement for a label. Annex A of NFPA 101 states that gasketing should not be necessary in order to limit the passage of smoke to an acceptable level, as long as the door is relatively tight-fitting.
Roller latches – friction bolts designed to hold the door in the closed position, are not allowed by NFPA 101 for most patient room doors in new health care occupancies, except in acute psychiatric settings where the clinical needs of patients require protective measures for their safety. In this application, roller latches must keep the door closed if a force of 5 lbf is applied at the latch edge of the door.
Doors in existing facilities are required to have a means of keeping a door closed against a 5-lbf force, and the method of keeping the door closed must be acceptable to the AHJ. NFPA 101 allows roller latches to be used in existing health care occupancies if the building is equipped throughout with an automatic sprinkler system, however, this is not permitted by the Centers for Medicare and Medicaid Services (CMS). Facilities which receive funding from CMS must have corridor doors with positive-latching hardware – not roller latches. If a patient room is within a suite, a roller latch may be acceptable as the positive-latching requirement does not typically apply to doors within suites.
Door closers are not required by the current codes for patient room doors that are not fire door assemblies, although fire doors must be self-closing. Examples of health care corridor doors that would typically be fire rated include doors leading to exit enclosures and hazardous areas; doors in smoke barriers must also be self-closing or automatic-closing. A self-closing door serving a patient room could lead to a delay in discovery of a fire within the room, so automatic smoke detectors that are part of the building’s fire alarm system are recommended for rooms that have door closers. NFPA 101 restricts the use of hold-open devices on patient rooms to those that release when the door is pushed or pulled; doors should not be blocked by furniture, door stops, hooks, or plunger-type hold-opens.
Doors leading to rooms that do not contain flammable or combustible material, such as toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces are not required by NFPA 101 to have doors that are constructed to resist the passage of smoke. These doors do not require positive latching hardware, and ventilating louvers or transfer grilles are allowed.
International Building Code
Chapter 4 of the International Building Code (IBC) contains special requirements for certain occupancy types – for example: high-rise buildings, motor-vehicle-related occupancies, and special amusement buildings. The chapter includes a section on Group I-2, which pertains to hospitals, nursing homes, detox facilities, and psychiatric hospitals. Section 407.3 (2015, 2018, 2021 editions) requires corridor walls in I-2 occupancies to be smoke partitions. Although section 710 of the IBC details requirements for doors in smoke partitions, section 407.3.1 contains specific requirements for I-2 corridor doors, so those requirements would apply instead of section 710.
Section 407.3.1 states that corridor doors (with the exception of doors required to be rated as an incidental use area and doors that are part of an exit enclosure), are not required to have a fire protection rating. These corridor doors are not required to be self-closing or automatic-closing as the staff is expected to close the doors to patient rooms if there is a fire, or to evacuate patients to an adjacent smoke compartment, but the doors must provide an effective barrier to limit the transfer of smoke. Corridor doors must have positive-latching devices – including constant-latching flush bolts on pairs of doors – and roller latches are not permitted. The IBC Commentary states, “This provision is primarily intended to apply to care recipient sleeping room corridor doors,” however, it may apply to other auxiliary rooms such as exam rooms and support spaces that are not fire rated.
One question that comes up quite often with regard to the IBC requirements for patient rooms is whether gasketing is required in order to limit smoke infiltration. While there is a stated limit for air transmission for fire door assemblies in corridors and smoke barriers, patient room doors do not fall into that category. There is no mention in paragraph 407.3.1 of smoke infiltration or UL 1784 – Air Leakage Tests of Door Assemblies and Other Opening Protectives, so gasketing is not mandated by this section. Prior to the 2015 edition of the IBC Commentary, there was a reference that caused a lot of confusion. When addressing the section on smoke and draft control doors, the Commentary stated: “Section 407.3.1 requires corridor doors in Group I-2 to ‘limit the transfer of smoke’; therefore, those doors must meet this section.” Although there was no code requirement for patient room doors to meet the limitations for smoke and draft control doors, some AHJs expected patient room doors to comply with the stated limits for air transmission based on the Commentary language. The incorrect statement was removed from the 2015 edition of the Commentary.
Another common question is whether patient room doors are required to be inspected annually, as fire door assemblies are. The general consensus is that because the doors are not fire door assemblies, the annual inspection and documentation is not mandated, but the doors, frames, and hardware must be kept in proper working order. Corridor doors that are fire door assemblies, such as doors leading to stairwells or incidental use areas that require a rating, would be subject to the annual inspection. Doors required to comply with NFPA 105 – Standard for Smoke Door Assemblies and Other Opening Protectives would also have to be inspected annually, but the model codes do not require health care corridor doors to meet this standard. The Joint Commission issued a bulletin clarifying this in 2018.
The requirements of the model codes have helped to reduce the frequency of fatal fires in hospitals and nursing homes, improving life safety for patients and staff. Properly-maintained corridor doors can help to protect patients sheltered in their rooms during a fire. For more information on the requirements for patient room doors in a health care facility, refer to the codes and standards that have been adopted by the facility’s jurisdiction. The AHJ is responsible for enforcing these requirements, and has the final say.
*Note: For doors protecting pass-through openings, NFPA 101 allows a maximum clearance of 1/8-inch at the bottom of the door. These are typically small openings used for passing medication or equipment into the patient room. Because the bottom of the pass-through door is normally above the neutral pressure plane that would occur during a fire, the clearance at the bottom of these doors is more limited than the clearance for a standard door.
For more information on codes and applications that apply to health care facilities, visit iDigHardware.com/healthcare.
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I think you may have a typo in paragraph six, on door closers. Did you mean to say, “…although they are mandated FOR fire door assemblies…”? Otherwise, great article!
You’re right! Thank you!!
The information was in accordance with my years of healthcare experience. There used to be and maybe still is a requirement for door closers in psychiatric hospital patient room doors. As I recall doors could not be held open and had to be self closing and, of course, latch up. This was a troublesome requirement because of the nature of psychiatric patients. Staff was always concerned about having all these folks behind self-closing doors and the social nature of the patients caused them to block doors on their own. This requirement held on for many years and before I retired was still being enforced by the authority having jurisdiction.
Interesting…I’ve never run across this. I was in a psychiatric facility recently and the doors weren’t self-closing. Maybe the code has changed?
No need to explain why you were in a psychiatric facility. All of us in this industry will probably end up there eventually. 🙂
I was only there temporarily – to look at a door! 🙂
Is there any article you posted on STC Rated doors in Health Care facilities.
Hi Maharoof –
I haven’t really done on article on STC doors, except the one on classroom acoustics. What would you like to see covered in such an article?
Thanking you for your quick response..
I am looking for any article related to the Fire rated STC doors and non fire rated STC doors in health care facilities. In a job consultant is asking for a STC rating of 55 which very high for almost all the doors. Is it a good idea to give such rating or there is any code requirments / comments?
STC 55 is very high, especially since many doors in health care facilities are left open most of the time. I don’t know of any code requirements or guidelines that would be looking for an STC of 55 in health care. The price may change their mind.
Yes it’s very high and normally used in places like music studios etc. I am looking for a technical documents to defend this kind of STC rating in health care facilities. If you have something, pls let me know.
I’m sorry Maharoof – I don’t have anything on that.
Lori. This subject has been a little confusing to me, so I hope you can clarify. I am inspecting a healthcare facility and have many patient room doors that are in 1hour fire walls and 1 hour fire barriers. These wall ratings are clear on the Life Safety Prints. I have read the “corridor exclusion ” in NFPA 101 many times as it relates to health care facilities. Does NFPA 101 exclude these doors from being required to be inspected because they are also in a corridor wall? Most of these doors are deficient per NFPA 80. If these doors are excluded from being inspected and they are deficient then how can the 1 hour wall requirement be maintained? Thank you
Hi Mark –
If the doors in these walls are not fire doors / are not required to comply with NFPA 80, I don’t know of anything that would prompt an annual inspection. With that said, it is the responsibility of the owner or facility manager to keep the doors code-compliant, including the requirements for positive-latching and minimal clearances.
Hey Lori. Some of the doors in question are rated and labeled, some have construction labels and some are not labeled. All of these doors are in the same 1 hour fire barrier. I understand the minimum requirements for these doors. How can these doors meet (compliment) a 1 hour wall rating or in the doors case a 20 min rating or 45 min rating if the doors are not NFPA compliant. I understand that they are not required to be inspected but a facility still may choose to do so. Thank you
A facility could definitely choose to have them inspected, and it is the facility’s responsibility to keep them functioning properly regardless. It would make a lot of sense for a health care facility to document the condition of these openings and avoid problems when it’s time for their CMS/Joint Commission inspection.
A related question to your article. As I read the NFPA 101 (2015), I don’t see a requirement for closers on suite doors in chapter 18. However, the IBC (2012) says I-2 suites are bounded by smoke partitions. So then i go to 710.5.2.3 and read this: “Where required elsewhere in the code, doors in smoke partitions shall be self- or automatic-closing…”. The “where required elsewhere” phrase is throwing me off…so does that mean my suite walls need closers on the doors or not?
Hi Ben –
If it doesn’t say in Chapter 18 that doors within suites need closers, then in my opinion 710.5.2.3 does not apply.
Nice summary of requirements. I have nurse server cabinets in corridors (not inside suites) with roller latches on several floors of hospital and am looking for acceptable (and cost-effective) resolution. Suggestions? Someone had recommended the sort of magnet “latch” you encounter on old medicine cabinets over sinks/vanities in homes, where you push hard once to release magnet, but ANY sort of magnetic latch is not considered “positive latching,” correct? How have others corrected this issue?
Hi Melissa –
Do these cabinets contain combustible materials? I’m just wondering if they would be exempt like a bathroom. A magnetic catch would not be considered positive-latching. I think most health care facilities use latchsets/locksets, but I’ll post something next week to ask the readers of iDigHardware for some ideas.
Yes, they contain combustibles. I know that because CMS prohibits ALL roller latches in corridors, there are no exemptions for these. They must be positive latching (and have no gaps greater than 1/8″). CMS has been very clear on that, and I’ve seen many LS consultants confirm the roller latches in corridors are not acceptable- even if “just” on nurse server doors. (Unfortunately, making the area a suite is not realistic.) So my confusion is just how to best correct: I’ve had some say magnetic catches are acceptable if they can meet the 5-lb pressure rule. Others disagree.
I have a question on a pair of Corridor doors with an inactive leaf is there any documentation that says the bottom automatic flush bolt has to latch I have come across a situation were there was a set of Corridor doors were they didn’t drill out a hole for the bottom flush bolt, does any body have an information that states that it has to latch I tried to explain that if it come on the door with the hardware that it should work.
Latch location or something that states the locations and why it needs to latch in that location.
Im finding it hard to find any information on this if anyone can help it would be appreciated.
Hi Terry –
If there is a bottom flush bolt, it’s definitely supposed to latch into a strike. I can’t think of anything specific to point to in the codes or standards, although the Handbook for NFPA 80 mentions the projection of the bolt into the strike. If you can identify the manufacturer, their installation instructions will show the bottom bolt and strike, and the instructions are part of the listing for components of a fire door.
I will look at the hardware instructions and see what it says thank you again for your help.
I’m needing help again I was asked about removing the push pull on a patient room door in a health care occupancy and installing a keypad is there any requirements that says you have to use a push pull on patient room doors.
Hi Terry –
I can’t think of any reason that a push plate and pull would be required, but it’s hard to say without knowing more about the situation. Make sure there’s free egress from the room and the new hardware can be operated within the requirements of the adopted code.
I see that patient rooms that are in a corridor are required to have auto flush bolts, but what if they are within a suite? My pairs are within a suite and are not rated or even in smoke walls. They are unequal pairs (3-0/1-0). Can we provide the 1’0 leaf with manual flush bolts, therefore eliminating the need for a closer and coordinator?
Hi Ginger –
Usually doors within a suite are not required to be self-latching, but on the inactive leaf I think I would still use a constant-latching top bolt (and maybe skip the bottom bolt). You wouldn’t need a closer or coordinator, and the constant-latching bolt would be easier for staff than manual flush bolts.
My mom is in a situation where she is not capable of opening the door of her suite so she has to summon an aide to do this. She is in a wheelchair. The facility does offer an automatic door opener at our expense. Are there any regulations requiring an assisted living facility to provide the resident the ability to open and close their room door on their own without assistance from someone else?
Hi Jim –
If the door to your mom’s suite is compliant with the accessibility and egress requirements for a manual door, I don’t know of a regulation that would mandate an automatic operator.
Lori, Do you know if Door Closers would be required on Bathrooms on a Smoke Rated Wall in a Psychiatric Facility???
Hi Jeff –
If it is an I-2 occupancy and the doors are in corridor walls, closers are not usually required. But I would check the use group and wall type to make sure.
Clarification request please…..recently cited by Ks FM for top gap exceeding half inch at latch side, but for non-rated corridor doors (Resident Rooms) in a long term care facility.
I’m not finding this as a specific requirement in the language, other than to acquiesce to the AHJ ruling. This seems to be a more recent series of citations just within the last couple of years so has there been a clarifying ruling they might be going by?
Also not finding precise language to argue the citation?
Hi Frank –
I think the Joint Commission limits the clearance on corridor doors to 1/8-inch at the head, jambs, and meeting stiles. I asked them about this when I wrote this old post about rescue hardware: https://idighardware.com/2014/11/rescue-hardware-on-corridor-doors/. Unfortunately, the Joint Commission will now only answer questions submitted by accredited facilities (not by me). There is a form on their website where you can ask the question and see if there is an official bulletin. I looked but could not find one.
In regards to NFPA 101 Annex A what is meant by relatively tight fitting?
I remember something from the Joint Commission that I think said 1/8-inch, but I could not find the bulletin when I looked for it recently. If you are with an accredited health care facility, you can ask the Joint Commission this question using the form on their website. They no longer answer questions for me because I am not with a health care facility. 🙁