2012 Life Safety and Health Care Facility Codes - Door Inspections and Other Critical Inspection, Testing and Maintenance

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Meredith Clark
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Handouts The handouts were attached to the confirmation email.

1 2012 Life Safety and Health Care Facility Codes - Door Inspections and Other Critical Inspection, Testing and Maintenance Will begin at 1 pm Housekeeping Announcements Problems during the call? Press *0 to be connected to the Operator. Handouts The handouts were attached to the confirmation . If you were unable to access the handouts to print, please contact the Association at 614/ after the call and we can provide those for you. Evaluation Each person listening to the call must complete the evaluation form. FAX or mail to the Association (FAX: ). 1

Continuing Education Credit Wait 24 hours and then Go to http://www.efohca.org and click on Request Your Certificates in the column entitled Live Teleconferences & Webinars.

2 Continuing Education Credit Wait 24 hours and then Go to and click on Request Your Certificates in the column entitled Live Teleconferences & Webinars. Certificates are available for 1 year after the program date. Find your Facility name in the drop down list. If your facility name is not there, contact the Association office at You will enter all participants names at one time. Follow the on screen instructions. You will receive an when your attendance has been verified and your certificates are available for download. Please note: this course is considered a self study course by Ohio BELTSS. Administrators are reminded that BELTSS limits teleconference (home/self study) credits to a total of ten (10.0) per renewal period. 2

Recording This live program (as well as all previous webinars) are also available via CD recording. Please note that there are no CEUs available for listening to the recording.

3 Recording This live program (as well as all previous webinars) are also available via CD recording. Please note that there are no CEUs available for listening to the recording. Please contact the Association if you would like to purchase a recorded copy of a previous webinar. Also for those listening to the recording, please note the there may have been changes since the live broadcast of this program. Please contact OHCA or the speaker for clarification. Today s Format 90 minutes available for presentation & questions Questions? During the presentation: you can type your questions There will also be time for live questions & answers at the end of the presentation and the operator will explain that procedure 3

4 Today s Speakers Kenneth M. Daily - President, Elder Care Systems Group, Dayton, Ohio Over his 25 plus year career, Kenn has wide-ranging experiences in advancing longterm health care. Kenn has a strong reputation for designing integrated and customized solutions for clients to achieve organizational quality and compliance. Kenn is a member of the Ohio Health Care Association (OHCA) Board of Directors and Chair of OHCA's Life Safety Code/Disaster Management Committee. He also serves on the American Health Care Association's Life Safety Committee and the National Fire Protection Association's Health Care Section where he also serves on its Executive Committee. Kenn is a recognized author and recently completed editing the NFPA's Life Safety Code Guidance as well as authoring Life Safety Code Essentials for Skilled Nursing Facilities' ECSG, Critical LSC Inspections Doors, Sprinklers, Electrical KENN DAILY, LNHA KENN@QISSURVEY.COM 4

NFPA Codes adopted effective July 5, 2016 101 Chapter 19 Existing 101 Chapter 18 -New Facilities Reference Codes NFPA 10 Fire Extinguisher 2010 NFPA 13 Sprinklers 2010 NFPA 25 Sprinkler

5 NFPA Codes adopted effective July 5, Chapter 19 Existing 101 Chapter 18 -New Facilities Reference Codes NFPA 10 Fire Extinguisher 2010 NFPA 13 Sprinklers 2010 NFPA 25 Sprinkler Testing 2010 NFPA 70 Electrical 2009 NFPA 72 Fire Alarm NFPA 80 Fire Doors 2010 NFPA 105 Smoke Doors 2010 NFPA 220 Construction NFPA 96 Range Hood 2011 NFPA 110 Generators

Doors NFPA 80 Standard for Fire Doors 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in surfaces.

6 Doors NFPA 80 Standard for Fire Doors As a minimum, the following items shall be verified: (1) No open holes or breaks exist in surfaces. (2) Glazing, vision light frames, and glazing beads are intact. (3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order. (4) No parts are missing or broken. (5) Door clearances do not exceed the clearances listed. 6

active leaf. (pairs only) (8) Latching hardware operates and secures the door when it is in the closed position.

7 Standard for Fire Doors As a minimum, the following items shall be verified: (6) The self-closing device is operational (7) If a coordinator is installed, the inactive leaf closes before active leaf. (pairs only) (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed. (10) No field modifications to the door have been performed. (11) Gasketing and edge seals are inspected. Means of Egress K226 Horizontal exits, exit doors or exit access doors cannot be painted/disguised in a manner that obscures their use as a door. 18/

8 Signs on Fire Doors There are two very important conditions regarding signage on fire doors. 1. Signs are for informational purposes only and must not exceed 5% of the area of the face of the fire door that they are attached 2. Signs can only be attached to the fire door with an adhesive. Attaching a sign by using means such as nails or screws are not permitted as they can, and most likely will, void the label on the fire door and affect its performance under fire conditions. Section of NFPA 80 Fire-rated Door Clearances The clearances between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs, shall be 1/8 + 1/16 for steel doors and shall not exceed in. 1/8 for wood doors Clearances shall be measured from the pull face of the door(s). 8

9 Clearances Under Doors Swinging Doors with Builders Hardware Maximum Clearance of 3/4 Under Door Bottom [ ] Smoke Doors Maximum clearance of 1 under door bottom - the doors shall be close fitting within operational tolerances Field Modifications NFPA 80 Chapter 4 A. Function Holes for Mortise Locks/Latches B. Holes for Labeled Door Viewers C. Round Holes for Surface Applied Hardware (up to 1 in Diameter) D. Through bolts , and

Field Modifications That May NOT Permitted Doors A. No Vision Panel Cut Outs B. No Louver Cut Outs C. No Mortise Lock Pockets D. No Face or Edge Bores for Bored Locks E.

10 Field Modifications That May NOT Permitted Doors A. No Vision Panel Cut Outs B. No Louver Cut Outs C. No Mortise Lock Pockets D. No Face or Edge Bores for Bored Locks E. No Mortise Hinge Preparations Frames A. No Mortise Hinge Preparations B. No Cut Outs C. Not Holes Cut for other purposes Fire and Smoke Door Inspections Qualified Training 02/03/17 10

11 Basis of Requirements NFPA 101 requires annual fire and smoke door inspections (Section 18/ ) which then requires compliance with Section which includes Section requires compliance with: NFPA 80, Standard for Fire Doors and Other Opening Protectives 2010 Edition Section addresses inspections, testing and maintenance NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives 2010 Edition (Section 5.2) Section 5.2 addresses inspections, testing and maintenance Door Inspection - NFPA 80 Section requires all fire and smoke doors to be inspected and tested, including: 1. Fire rated labeled doors 2. Doors in exit enclosures - typically stairwells and exit passageways 3. Doors in smoke barriers 4. Doors in other fire resistance rated walls such as hazardous areas and fire pump enclosures 11

12 Doors Testing K 211 Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/ through 18/ Inspection and testing requirements for fire-rated door assemblies in accordance with NFPA 80. Inspection and testing requirements for smoke door assemblies in accordance with NFPA 105 Applies to new and existing installations Inspected and tested not less than annually Written record shall be signed and kept for inspection Repairs shall be made without delay Who Can? The inspection is the responsibility of the owner, performed by individuals with knowledge and understanding..so as an owner, does NFPA require me to bring a third-party in to my facility to inspect my fire doors? Performed by individuals with knowledge and understanding; and that written records are maintained. NFPA 80 allows for individuals on the facility staff to perform this function if they choose. 12

Door Inspection Requirement This packet has been developed to provide guidance and training to ensure that individuals inspecting and testing door are prepared and qualified.

13 Door Inspection Requirement This packet has been developed to provide guidance and training to ensure that individuals inspecting and testing door are prepared and qualified. Door assemblies shall be inspected by a QUALIFIED INDIVIDUAL annually Reviews operation, door clearance, coordinator, latch and closer Record kept for AHJ inspection Fire-rated Door Assemblies NFPA 80 Labels are present and legible No holes or breaks of door or frame No signs of damage to the door, frame, hinges, and hardware No parts are missing or broken Door clearances are appropriate Self-closing device operating properly If installed, the coordinator is working Latching hardware operates No auxiliary hardware installed that would interfere with operation No field modifications that would void the label Gasketing and edge seals, if required, are inspected 13

14 Smoke Door Inspection NFPA 105 Smoke door assemblies shall be inspected annually. Doors shall be operated to confirm full closure. Hardware and gaskets shall be inspected annually, and any parts found to be damaged or inoperative shall be replaced. Tin clad and Kalamein doors shall be inspected regularly for dry rot. A written record shall be maintained and shall be made available to the authority having jurisdiction. Fire-rated Doors Fire-rated doors are an integral part of not just the building s passive fire-protection system but the building s overall fire protection. A properly operating fire door, just like a properly operating fire damper, is a key component in the compartmentalization of a building to limit the spread of fire and restrict the movement of smoke. 14

15 For the fire door to operate successfully, the entire fire assembly must operate, and the fire door is just one part of the overall fire assembly. The assembly is composed of the fire door, frame, fire exit hardware, door closers, hinges, locks, door bolts, and other door components that when combined provide varying degrees of fire protection that is contingent on the door fire rating (e.g. 45 minutes, 90 minutes). In addition to all of the components of a fire door assembly, there are multiple categories of fire doors: horizontal sliding; fire shutters; swinging; vertically sliding; chutes; overhead rolling fire doors. Understanding the function and parts of door assemblies 15

16 Door Label Fire rated permanent label attached and readable. 16

3), steel door frames that are well set in the wall may be judged compliant

17 NFPA 80 Annex NFPA 80 annex note (addition information which is not enforceable (A ), steel door frames that are well set in the wall may be judged compliant even when frame label is not legible. The door label, however, must be legible. At this point we do not know how SURVEYORs will interpret Door Parts 17

match the capabilities of the door and frame used.

18 Fire Door Hardware Labeling In order for a fire door and frame to provide protection against the spread of heat and fire, the hardware used must match the capabilities of the door and frame used. Check for UL listing and ensure hardware is tested for the rating it is matched to. NFPA

19 Fire Exit Hardware When fire doors are labeled requiring Fire Exit Hardware, ensure labels on the hardware match the label on the door. NFPA 80, Chapter 6 Fire doors and door hardware are subject to failure due to their constant usage in high traffic areas, such as busy corridors. Constant usage can lead to misalignment of the door, which could potentially lead to failure of the door to close in the event of a fire, which the NFPA claims to be the most common failure of fire doors during an actual fire. 19

Other common non-compliant issues are holes or openings in the fire door assembly, improper gaps, missing labels, failure of latching hardware to operate,

improper field modifications, and numerous other problems. All this must be addressed When should repair work begin?

20 Other common non-compliant issues are holes or openings in the fire door assembly, improper gaps, missing labels, failure of latching hardware to operate, missing screws, door coordinator operating improperly, nonworking self-closing devices, missing gasketing, improper kick plate (protective plate) sizes, improper field modifications, and numerous other problems. All this must be addressed When should repair work begin? If an inspection shows a deficiency on any fire protection device including fire doors, repair work should start without delay. You should also report any findings the same day to your direct supervisor or manager. 20

It is recommended that a facility identify all doors to be

21 Smoke/Fire Door Inspection Door inspection tool was developed for facilities use Complete one form for each door inspected. It is recommended that a facility identify all doors to be inspected on a drawing/layout of the facility to track inspections. 21

22 Completing Inspection Facility Tester Name Date Door Type: Fire Smoke Rating Location Locating Fire/ Smoke Doors Check facility as built floor plans. Tour facility and evaluate each door opening looking for labels. Remember Stairtower and exit doors Smoke wall doors Fire Rated labeled doors Doors to harardous spaces Door openings. separation between adjoining facilities (NF to ALF) placed at building separations. 22

23 Filling Out Inspection Operation r Swings freely r Closes properly r Latches properly r Other Frame r Label present and legible r Is secure r No open holes/breaks r Frame not rusted through r Gaskets intact r Other Door r Label present and legible r Correct Clearance r No open holes/ breaks r Glazing/vision light frames intact r Not Damaged / delaminated door r Door not rusted-through r No non-compliant field modification r No visible signs of damage r Other Door Closer r All hardware installed r Strike in good shape r Securely installed r Other 23

24 Filling Out Inspection (cont.) Hinges r Correct r Securely installed r Other Flush Bolts r Correct r Securely installed r Other Lockset / Hardware r All hardware installed r Strike in good shape r Securely installed r Coordinator working properly r Other Fire Exit Hardware r All hardware installed r Strike in good shape r Securely installed r Other Other r No items that interfere installed r No non-compliant field modification r Door has appropriate signage r Any signage is properly affixed r Other Sprinkler Head Inspection Annual) Inspect all sprinkler heads, including the piping and fittings. Hanger/ seismic bracing Pipes and fittings Sprinkler heads Documented Sprinkler heads must be free of foreign materials such as dirt, grime, rust, painters tape, etc. 24

25 Electrical Equipment Testing K921 Facility must establish policies and protocols for the test intervals and types of tests for all patient care related electrical equipment, whether owned or leased. Documentation must be maintained, with records kept as required by the facility s record retention policy. Tests should include: Date of test Unique equipment ID number (what was tested) What was met and not met during the test (result) 10.4, Electrical Equipment Testing K921 Non patientcare related equipment, whether facility owned or resident owned, must be visually inspected by staff to verify that the device is in proper equipment if it will have contact with residents. 25

Testing & Inspection Receptacles K 914 Maintenance and Testing Hospital-grade receptacles at patient bed locations Receptacles not listed as hospital-grade at these locations are

The physical integrity of each receptacle shall be confirmed by visual inspection 2. The continuity of the grounding circuit in each electrical receptacle shall be verified 3.

26 Testing & Inspection Receptacles K 914 Maintenance and Testing Hospital-grade receptacles at patient bed locations Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months (NFPA 99) Testing of Electrical Outlets NFPA lists the following elements: 1. The physical integrity of each receptacle shall be confirmed by visual inspection 2. The continuity of the grounding circuit in each electrical receptacle shall be verified 3. Correct polarity of the hot and neutral connections in each receptacle shall be confirmed 4. The retention force of the grounding blade of each receptacle (except locking-type receptacles) shall not be less than 115g 26

27 LSC compliance The routine inspection, testing, and maintenance of building systems is an important component of Life Safety Code compliance. A significant number of deficiencies occur due to the lack of documentation of this inspection, testing, and maintenance. Survey Documentation Facility Layout Features of fire protection - sprinklers and doors NFPA 99 Risk Assessment Emergency Battery Lighting Monthly 30 sec. test Annual 90 min. test Fire/Smoke Dampers Test and lube every 4yrs. Fire/ Smoke Door Inspection Annual Electrical Equipment Annual PM Fire Alarm Monthly Fire Alarm Inspection Quarterly, semi-annual and annual testing Batteries every 4 yrs. 27

28 Survey Documentation Fire Drills Monthly (one/month, per shift, per quarter) Fire Pump Weekly, Monthly, Annual Generator Weekly Monthly Load Bank (if necessary) 36 month exercise Non-Hospital Grade - Electrical Plug Inspection - Annual Hood Suppression Monthly inspection Semi-annual Survey Documentation Sprinkler System Pressure gauges readings recorded weekly/dry Pressure gauges readings monthly/wet Quarterly and Annual Annual head inspection 5yr. internal inspection Smoke detectors At install, year and every 2 years Misc. Items Elevator state certificate/ Annual PM Boiler certificate Fire hydrant HVAC Annual PM Facility Policies Fire - Evacuation Fire Drill - Procedures Fire Watch Smoking 28

29 Kenneth Daily, LNHA Elder Care Systems Group Comprehensive consulting for life safety system and disaster management Consulting and education focusing on quality improvement, survey compliance, and facility management. Mock surveys and audits Conduct Fire Safety Evaluation Surveys Policy and procedure development Professional development and training 29

Fire and Smoke Door Inspections Qualified Training 02/03/17

Fire and Smoke Door Inspections Qualified Training 02/03/17 Basis of Requirements NFPA 101 requires annual fire and smoke door inspections (Section 18/19.2.2.2.1) Sections 18/19.2.2.1 require compliance