Fire and Smoke Door Inspections
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April 22, 2021
Ohio Health Care Association
Since January 2018 CMS and ODH has been enforcing the requirement for healthcare facilities to inspect, test and maintain fire doors annually.
According to the NFPA’s Life Safety Code 101 and 80 requires that in health care facilities, fire door assemblies are required to be inspected annually in accordance section 184.108.40.206. The inspection and testing of fire door assemblies shall be performed by qualified individuals with knowledge and understanding of the operating components of the type of door being subject to testing. Doors selected for inspection include:
• Doors in fire rated assemblies, such as doors in fire rated walls
• Exit enclosures and hazardous spaces with rated doors
• Certain fire rated labeled doors
With the adoption of the 2012 Life Safety Code effective July 5, 2016, CMS expects all healthcare organizations to be compliant with the requirements including the NFPA 80-2010 edition, which requires all fire-rated door assemblies to be inspected annually. The requirements for the annual inspection include the following:
• Is the door label present and legible?
• Is the door and frame free from holes and breaks in all surfaces?
• 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?
• Does the latching hardware operate and secure the door in the closed position?
• Is the door assembly free from are auxiliary hardware items which could interfere with its operation?
• Has the door been modified since it was originally installed?
OHCA, in conjunction with AHCA, has prepared door inspection training and an inspection form to be used in meeting the annual fire door inspection requirement. The training packet has been developed to provide guidance and training to ensure that individuals inspecting and testing doors are prepared and qualified.
This webinar will review the qualified training necessary to complete the fire door inspection and provide facilities the necessary documentation tools to complete these.
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