This is a reminder for health care and long term care providers that full compliance with the annual fire door assembly inspection and testing requirement is expected by Jan. 1, 2018. Initially, inspection and testing was due by July 6, 2017, but CMS extended the deadline to Jan. 1st in Survey and Certification Letter No. S&C 17-38-LSC.
Annual inspection and testing in accordance with the 2010 NFPA 80 is required by Life Safety Code section 8.3.3.1 for all fire door assemblies. Non-rated doors are not subject to the NFPA 80 requirement, but CMS indicates they should be routinely inspected as part of the facility maintenance program, as all required life safety features and systems must be maintained in proper working order.
Chapter 5 of NFPA 80 specifies elements that must be verified:
- Is the door and frame free from holes and breaks in all surfaces?
- Are all the glazing, vision light frames and glazing beads intact and securely fastened?
- Are the doors, hinges, frame, hardware and threshold secure, aligned and in working order with no visible signs of damage?
- Are there any missing or broken parts?
- Is the clearance from the door edge to the frame no more than 1/8 inch? Is the door undercut no more than ¾ inch?
- Is the self-closing device operational? Does the active door leaf completely closes when operated from the full open position?
- Does the inactive leaf close before the active leaf when a coordinator is used?
- Does the latching hardware operate and secure the door in the closed position?
- Is the door assembly free from auxiliary hardware items which could interfere with its operation?
- Has the door been modified since it was originally installed (voiding the label)?
- If gasketing and edge seals are installed, have they been verified for integrity and operation?
Providers should have a record verifying the inspection of these elements for each door, signed by the person who inspected it; the signature/name should be legible, so the Fire Marshal can talk to the person who did the inspection.
An NFPA 80: Standard for Fire Doors and Other Opening Protectives Handbook is available for to purchase and download from the National Fire Protection Association. If purchasing, be sure to specify the NFPA 80: 2010 Edition.
