Developing a Healthcare Facility Fire Door Inspection Program

Developing a Healthcare Facility Fire Door Inspection Program WELCOME Moderator: Richard Schieferdecker support.webinato.com Audio QUESTIONS How To Ask a Question: 1

POLLING There will be occasional interactive poll questions Developing a Healthcare Facility Fire Door Inspection Program WEBINAR SERIES Two (2) sessions Approximately 90 minutes each Handouts and survey tools available Completion certificate On demand access 2

SESSION ONE AGENDA Background Qualifications Applicable Doors Session One Creating an Inventory Survey Process SESSION TWO AGENDA Door Components Survey Criteria Documentation Session Two Survey Tools Common Findings WEBINAR OBJECTIVES Upon completion, participants will have the ability to: Establish an inspection program Determine applicable doors Develop a door inventory Inspect fire rated door assemblies and smoke door assemblies Develop inspection documentation 3

BACKGROUND 2000 Life Safety Code (NFPA 101) 2012 Life Safety Code (NFPA 101) Adopted July 2016 Instituted November 2016 CODE PATH: 2012 LIFE SAFETY CODE Chapter 19 Reference to Chapter 7 Chapter 7 7.2.1.15.2 Reference NFPA 80 & NFPA 105 NFPA 80 & 105 NFPA 80 (Standard for Fire Doors and Other Opening Protectives) NFPA 105 (Standard for the Installation of Smoke Door Assemblies and Other Opening Protectives) CODE PATH: REFERENCED STANDARDS NFPA 101 (2012 Edition) NFPA 80 (2010 Edition) NFPA 105 (2010 Edition) 4

AUTHORITIES HAVING JURISDICTION CMS Developed K 363 No additional guidance The Joint Commission EC.02.03.05 EP25 Recent clarifications in EC News and Perspectives Other Accrediting Agencies / State Survey Agencies QUALIFICATIONS NFPA 80 Language Functional testing of the fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing No reference to certified QUALIFICATIONS NFPA Definition Qualified A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who, by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project Focus on professional standing, skill, knowledge, training, and /or experience 5

QUALIFICATIONS Internal Staff Staff Carpenter General Maintenance / Physical Plant Staff External Vendor Certified Fire Door Inspector Life Safety Consultant Licensed Carpenter External Vendor Support to Train Internal Staff DEVELOPING AN INVENTORY WHAT DOORS? Determining what doors to survey Fire barriers Smoke barriers Hazardous areas Chutes and shafts DEVELOPING AN INVENTORY WHAT DOORS? Fire Barrier Doors Building separations Occupancy separations Stairwell enclosures *check your life safety drawings to determine barriers 6

DEVELOPING AN INVENTORY WHAT DOORS? Smoke Barrier Doors Separate smoke compartments May or may not be labeled fire doors Don t include courtesy doors *check your life safety drawings to determine barriers DEVELOPING AN INVENTORY WHAT DOORS? Hazardous Area Enclosures Non sprinklered spaces New construction Generally 45 minute doors in 1 hour rated enclosures *check your life safety drawings to determine hazardous area enclosures DEVELOPING AN INVENTORY WHAT DOORS? Chute and Shaft Doors Trash chutes (inlet and outlet) Linen chutes (inlet and outlet) Shaft access doors *check your life safety drawings to determine chute and shaft locations 7

DEVELOPING AN INVENTORY WHAT DOORS? Unique Situations Rated patient / resident room doors Rated doors that are not part of a rated barrier DEVELOPING AN INVENTORY WHAT DOORS? Patient / Resident Room Doors Not required to be rated May be rated anyway Not a true fire door assembly since door closer not required Joint Commission not required to be included CMS no guidance *RPA suggestion do not include in inventory or inspection. Still must meet corridor door requirements. DEVELOPING AN INVENTORY WHAT DOORS? Misc. Rated Doors (not part of a rated enclosure) Not required to be rated May be rated anyway Joint Commission not required to be included CMS no guidance 8

DEVELOPING AN INVENTORY WHAT DOORS? May do Nothing May Include in Inventory & Inspection May Remove Labels If the labels are removed, consider retaining the labels and documenting where they came from Consider checking with your local AHJ May Replace Doors DEVELOPING AN INVENTORY WHAT DOORS? Doors Not to Include WON doors Fire or Smoke shutters Smoke Curtains or other smoke containment devices *These doors/curtains are covered in separate sections/standards for inspection, testing, and maintenance. DOOR CATEGORIES Eleven (11) categories of doors Fire rated door assemblies (fire barriers) Doors to hazardous areas (rated enclosures) Shaft access doors (rated shaft enclosures) Trash chute inlet Trash chute discharge Linen chute inlet Linen chute discharge Smoke doors (new nonrated) Smoke doors (new rated) Smoke doors (existing nonrated) Smoke doors (existing rated) 9

SURVEY CHECKLIST SURVEY TOOLS SURVEY CHECKLIST SURVEY TOOLS SURVEY CHECKLIST SURVEY TOOLS 10

DEVELOPING AN INVENTORY PHASES Phase I Identify door assemblies to be included Document door ID, location, type and rating Consider a spreadsheet Identify door locations on a drawing DEVELOPING AN INVENTORY PHASES DEVELOPING AN INVENTORY PHASES 11

DEVELOPING AN INVENTORY PHASES DEVELOPING AN INVENTORY PHASES Door Components 12

DEFINITIONS Labeled: Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the AHJ and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in specified manner. A fire door with a label is a labeled component of a listed assembly Listed: Equipment, materials, or services included in a list published by an organization that is acceptable to the AHJ and concerned with evaluation of products or services, that maintains periodic inspection of production of listed equipment or materials or periodic evaluation of services, and whose listing states that either the equipment, material, or service meets appropriate designated standards or has been tested and found suitable for a specified purpose. A fire stop system is part of a listed (barrier) assembly (approved for use, but no label is present) DEFINITIONS Fire Door Assembly: Any combination of a fire door, a frame, hardware, and other accessories that together provide a specific degree of fire protection to the opening. Classification: Fire doors and fire windows shall be classified by designating a required fire protection rating expressed in hours or fractions thereof. Fire door assemblies have fire rating durations expressed as 20,30,45,60,90,and 180 minutes. May also be expressed as 1/3, 1/2, 3/4, 1, 1 1/2, 3 hours DEFINITIONS Builder s hardware: Individual listed or labeled hardware products are usually suitable for fire door assemblies of any construction or hourly rating. Fire Door Hardware: Door hardware furnished for swinging and sliding fire doors by the door manufacturer as a component part of the listed door assembly Smoke Door Assembly: Any combination of a door, frame, hardware, and any other accessories that together restrict smoke movement through door openings by limiting the amount of air that can pass through the assembly. Does not include smoke partitions or corridor doors 13

DEFINITIONS WINDOWS AND GLAZING Fire Resistance Rated Glazing Tested as part of a fire resistance rated wall assembly in accordance with the Standard for Fire Tests of Building Construction and Materials DEFINITIONS WINDOWS AND GLAZING Fire Protection Rated Glazing Fire protection rated glazing materials are intended for installation in fire windows, fire doors, and fire door frames with transoms and/or sidelights that are provided with suitable glazing frame members. Unless otherwise indicated in the individual Classifications, these materials have not been investigated by UL to determine compliance with safety glazing requirements. DEFINITIONS WINDOWS AND GLAZING NFPA 101 2012 Table: 8.3.4.2 14

DEFINITIONS WINDOWS AND GLAZING NFPA 101 2012 Table: 8.3.4.2 DEFINITIONS WINDOWS AND GLAZING NFPA 101 2012 Table: 8.3.4.2 DEFINITIONS WINDOWS AND GLAZING NFPA 101 2012 Table: 8.3.3.12 15

COMPONENTS (APPURTENANCES) Components (Appurtenances) all must bear a label OR meet the specifications for that particular component Astragals Sweeps Closers COMPONENTS (APPURTENANCES) Door Bottoms Door ends COMPONENTS (APPURTENANCES) Hardware Hinges Latches Locks 16

COMPONENTS (APPURTENANCES) Lights (side lights) Louvers Vision Panels The Inspection DOOR CATEGORIES Eleven (11) categories of doors Fire rated door assemblies (fire barriers) Doors to hazardous areas (rated enclosures) Shaft access doors (rated shaft enclosures) Trash chute inlet Trash chute discharge Linen chute inlet Linen chute discharge Smoke doors (new nonrated) Smoke doors (new rated) Smoke doors (existing nonrated) Smoke doors (existing rated) * Rated doors that are not required to be rated 17

DOOR CATEGORIES Requirements vary based upon category of door See Inspection Criteria Tool Approximately 25 total inspection criteria DOOR INSPECTION COMPONENTS I. Latching hardware operates and secures the door when it is in the closed position. 18

II. The self closing device is operational, that is, the active door completely closes when operated from the full open position. III. No open holes or breaks exist in surfaces of either the door or frame IV. Door labels are clearly visible and legible V. Frame labels are clearly visible and legible 19

VI. Signage affixed to a door meets the requirements listed in NFPA 80 SIGNAGE Signage requirements per NFPA 80 Total area of attached signs shall not exceed 5 percent of the area of the face of the door Signs shall be attached to fire doors by use of an adhesive. Screws or nails shall not be permitted. Signs shall not be installed on glazing material in fire doors. Shall not impair or otherwise interfere with the proper operation of the fire door. In accordance with Manufacturer Listings Fire Door Informational Signage Door Width (in inches) 35 36 37 38 39 31 32 33 34 40 41 42 43 44 48 78 121 125 129 133 137 140 144 148 152 156 160 164 168 172 187 79 122 126 130 134 138 142 146 150 154 158 162 166 170 174 190 Door Height (in inches) 80 124 128 132 136 140 144 148 152 156 160 164 168 172 176 192 81 126 130 134 138 142 146 150 154 158 162 166 170 174 178 194 82 127 131 135 139 144 148 152 156 160 164 168 172 176 180 197 83 129 133 137 141 145 149 154 158 162 166 170 174 178 183 199 84 130 134 139 143 147 151 155 160 164 168 172 176 181 185 202 Maximum area of sign(s) permitted (in square inches) NFPA 80 2010ed 4.1.4.1 Sign Width (in inches) 14 15 16 8 9 10 11 12 13 17 18 19 20 21 22 10 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 11 88 99 110 121 132 143 154 165 176 187 198 209 220 231 242 Sign Height (in inches) 12 96 108 120 132 144 156 168 180 192 204 216 228 240 252 264 13 104 117 130 143 156 169 182 195 208 221 234 247 260 273 286 14 112 126 140 154 168 182 196 210 224 238 252 266 280 294 308 15 120 135 150 165 180 195 210 225 240 255 270 285 300 315 330 16 128 144 160 176 192 208 224 240 256 272 288 304 320 336 352 Area of sign(s) (in square inches) 20

VII. The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. VIII. No field modifications to the door assembly have been performed that void the label. IX. Corridor doors do not exceed a one (1) inch clearance at the bottom of the door 21

X. Door clearances at the door edge to the frame, on the pull side of the door, are not excessive bottom (3/4 ) and between (1/8 ) HOW TO FIX EXCESSIVE FIRE DOOR CLEARANCES Door undercut vs clearance Install door bottoms listed for that purpose 22

HOW TO FIX EXCESSIVE FIRE DOOR CLEARANCES Door undercut vs clearance Install door bottoms listed for that purpose HOW TO FIX EXCESSIVE FIRE DOOR CLEARANCES Side gaps Gasketing for the frame/door gap Meeting edges of door gaps Install door ends to minimize gap XI. No parts are missing, broken or damaged 23

XII. The door is free of nonrated protective plates >16" above the bottom of the door XIII. Vision panels are installed properly with a legible rating label XIV. Chute inlet doors positively latch 24

XV. Door is equipped with astragal, rabbet or bevel XVI. If a coordinator is installed, the inactive leaf closes before the active leaf. XVII.Vision panels and glazing beads are intact and securely fastened in place, if so equipped 25

XVIII.Automatic flush bolts in place and properly working on inactive door leafs XIX. Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. XX. Fusible links in place and not damaged 26

XXI. Gasketing and edge seals, where required, are inspected to verify their presence and integrity. XXII. There are not gaps around the door frame or the frame is not secured to the wall. XXIII.Center mullion does not restrict door opening or closing. 27

XXIV.New smoke barrier doors swing in opposite directions and have vision panels XXIV.Fire exit hardware in place where required Inspection Documentation 28

DOCUMENTATION PHASE Document inspection findings via the data collection tool (spreadsheet) Reference the appropriate checklist based on door type Determine any failing inspection components via the failure mode list (items 1 25) Document on the Findings Report (Phase II) DOCUMENTATION PHASE DOCUMENTATION PHASE Phase II 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Result: Pass or Fail Failure Mode Other Comments 29

Building Floor Location Door Number Leaves: Single or Double Barrier Type Door Type (See inspection checklist for criteria inspected to) Door Rating (in minutes) Result: Pass or Fail 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 North 11 Rm 11-100 Stair 26 F11101 Single 2hr Fire Fire Rated Door Assembly 90 Fail 3 6 Remove label North 11 Rm 11-101 Stair 26 F11102 Single 2hr Fire Fire Rated Door Assembly 90 Fail 5 6 North 11 Rm 11-120 Stair 28 F11120 Single 2hr Fire Fire Rated Door Assembly 90 Fail 3 10 North 10 Rm 10-120 Stair 28 F10120 Single 2hr Fire Fire Rated Door Assembly 90 Fail 3 10 North 10 North 10 North 10 North 10 Rm 10-100 Mechanical Rm 10-101 Mechanical Rm 10-102 Mechanical Rm 10-103 Mechanical F10100 Single 2hr Fire Fire Rated Door Assembly 90 Pass F10101 Single 2hr Fire Fire Rated Door Assembly 90 Fail 6 7 F10102 Single 2hr Fire Fire Rated Door Assembly 90 Fail 3 6 7 F10103 Single 2hr Fire Fire Rated Door Assembly 90 Fail 3 Failure Mode Comments Summary: Maintain, Repair, Replace, Date Repaired and/or Result: Remove Label, Remove Verified Complete Pass or Fail Rating 4/21/2017 DOCUMENTATION PHASE Phase II 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Result: Pass or Fail Failure Mode Other Comments Pass Fail 5 6 Fail 3 10 Fail 3 10 Pass Fail 6 7 Fail 3 6 7 DOCUMENTATION PHASE Sample Medical Center Fire / Smoke Barrier Door Assembly Report of Findings and Management Tool Phase I Phase II Phase III Other DOCUMENTATION PHASE 30

DOCUMENTATION PHASE DOCUMENTATION PHASE DOCUMENTATION PHASE 31

Building Floor Location Door Number Leaves: Single or Double Barrier Type Door Type (See inspection checklist for criteria inspected to) Door Rating (in minutes) Result: Pass or Fail 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 North 11 Rm 11-100 Stair 26 F11101 Single 2hr Fire Fire Rated Door Assembly 90 Fail 3 6 Remove label North 11 Rm 11-101 Stair 26 F11102 Single 2hr Fire Fire Rated Door Assembly 90 Fail 5 6 North 11 Rm 11-120 Stair 28 F11120 Single 2hr Fire Fire Rated Door Assembly 90 Fail 3 10 North 10 Rm 10-120 Stair 28 F10120 Single 2hr Fire Fire Rated Door Assembly 90 Fail 3 10 North 10 North 10 North 10 North 10 Rm 10-100 Mechanical Rm 10-101 Mechanical Rm 10-102 Mechanical Rm 10-103 Mechanical F10100 Single 2hr Fire Fire Rated Door Assembly 90 Pass F10101 Single 2hr Fire Fire Rated Door Assembly 90 Fail 6 7 F10102 Single 2hr Fire Fire Rated Door Assembly 90 Fail 3 6 7 F10103 Single 2hr Fire Fire Rated Door Assembly 90 Fail 3 Failure Mode Comments Summary: Maintain, Repair, Replace, Date Repaired and/or Result: Remove Label, Remove Verified Complete Pass or Fail Rating 4/21/2017 CM46 Making The Repairs REPAIRS Sample Medical Center Fire / Smoke Barrier Door Assembly Report of Findings and Management Tool Phase I Phase II Phase III Other REPAIRS Summary: Maintain, Repair, Replace, Remove Label, Remove Rating Phase III Date Repaired and/or Verified Complete Result: Pass or Fail 32

Slide 94 CM46 add information about pieces/parts allowed for making the repairs. Colin McKay, 3/29/2017

REPAIRS WHO DOES IT Internal Staff Carpenter General Maintenance, Facilities, Physical Plant Staff External Vendor Certified Fire Door Inspector / Firm Licensed Carpenter REPAIRS WHEN TO DO IT Repairs shall be made, and defects that could interfere with operation shall be corrected without delay Consider ILSMs in accordance with your organization s policy REPAIRS MATERIAL & PRODUCTS Damaged glazing must be replaced with labeled glazing (not wired glass) Broken components shall be: Repaired with labeled parts or parts obtained from the original manufacturer. Tested to ensure emergency operation and closing upon completion of the repairs. 33

REPAIRS MATERIAL & PRODUCTS When holes are left in a door or frame due to changes or removal of hardware or plant ons, the holes shall be repaired by the following methods: (1) Install steel fasteners that completely fill the holes (2) Fill the screw or bolt holes with the same material as the door or frame If repairs cannot be made with labeled components or parts obtained from the original manufacturer or retrofitted in accordance with Section 5.3, the fire door frame, fire door assembly, or appurtenances shall be replaced. REPAIRS FIELD MODIFICATIONS Where a field modification to a fire door or a fire door assembly is desired, the listing lab shall be contacted and a description of the modifications shall be presented to that laboratory. If the laboratory finds that the modifications will not compromise the integrity and fire resistance capabilities of the assembly, the modifications shall be permitted to be authorized by the laboratory without a field visit from the laboratory. Common Findings 34

TOP 10 FINDINGS IFDIA 1. Painted or missing fire door labels. 2. Excessive clearances around the perimeter of the door in the closed position. 3. Kick down door holders. 4. Auxiliary hardware items that interfere with the intended function of the door (barrel bolts and dead bolts, etc.) 5. Fire doors blocked in the open position. 6. Areas surrounding the fire door assembly blocked by furniture, equipment and/or boxes. Top 10 Findings IFDIA 7. Broken, defective or missing hardware items (latch bolts, and/or strike plates, closer arms, cover plates, etc.) 8. Fire exit hardware installed on doors that are not labeled for use with fire exit hardware. 9. Missing or incorrect fasteners. 10. Bottom flush bolts that do not project ½ into the strike. RPA s TOP 10 FINDINGS Rank Item # % Failure 1 3 36% Door or frame has open holes or breaks 2 10 Door clearances exceed clearances listed in NFPA 80 4.8.4 (3/4 undercut) and NFPA 80 28% 6.3.1.7 (1/8 gap) 3 7 18% Parts are missing or broken 4 1 17% Latching hardware does not operate or secures when it is in the closed position 5 5 16% Door frame rating label is not present and/or legible 6 12 13% Door has non rated protective plates 16+" 7 2 12% The self closing device is not operational 8 6 12% Signage affixed to a door does not meet the requirements listed in 4.1.4 (Max 5% of area of door, not affixed with fasteners, not installed on vision panels) 9 4 11% Door rating label is not present and/or legible 10 25 8% Hardware is not appropriate for the door (No fire exit hardware) NOTE: More than 1 failure on a door is possible. In fact, 55% have more than 1 problem. 35

WHAT IFS? NUANCES What if the labeled door is in a non rated wall/barrier? What if in years past door sweeps were added on the bottom of their doors, and now those sweeps are not good enough? What if a vision panel has wired glass without a rating label? CM53 WHAT IFS? NUANCES What about hospital frames? How do we address other occupancies: An attached Business Occupancy? Ambulatory Occupancy across the street? MOB across the street? ADDITIONAL INFO CERTIFICATIONS International Fire Door Inspector s Association (IFDIA) Door & Hardware Institute s Fire and Egress Door Assembly Inspection (FDAI) 36

Slide 107 CM53 as time allows Colin McKay, 3/30/2017

QUESTIONS THANK YOU Paul Dzurinda, Colin McKay & Dave Hood 37