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By Russ Banham

Beginning January 1, 2018, health care facilities will need to comply with new annual testing requirements of their fire and smoke doors. The new rule from the U.S. Centers for Medicare & Medicaid Services (CMS) cover the installation, care and maintenance of many types of doors and assemblies.

Although compliance originally was set for July 5, 2017, CMS extended the deadline to 2018, due to substantial health care industry questions and pushback. Given the broad sweep of the new rule, which harmonizes with NFPA 80 (the National Fire Protection Association’s standard for fire doors), the extension bought much-needed time for hospitals to prepare accordingly.

With the deadline nearing, health care facilities are confronting the harsh realities of complying with “an extremely complex regulation” that requires “substantial hospital actions,” says Kirk Kaiser, owner of Barrier Compliance Services, a nationwide containment contractor and Grainger’s exclusive national partner for fire and smoke barrier solutions. “Compliance is not a walk in the park.”


The new rules for fire and smoke doors recognize the unique nature of a health care facility. In the event of fire or smoke, expeditiously evacuating patients is a difficult life-and-death challenge, given the medical condition of patients who may be immobile, hooked up to life-sustaining machinery, or require wheelchairs or wheeled gurneys to be relocated. “Fire and life safety in a hospital is the most critical of any type of structure requiring evacuation,” Kaiser says.

Consequently, the emphasis is on protecting patients from fire and smoke while they are in the hospital. To do this, hospitals are physically compartmentalized to ensure a fire does not travel from one area to another. “Each room is blocked off from other rooms, with a different set of safety precautions required for each of these environments,” Kaiser explains.

Each room is composed of different components like a ceiling, floor, walls and door(s). Since fire doors open and close, they are part of a building’s passive fire protection system. Generally they are not constructed with the same degree of physical strength and integrity as the walls and ceiling. And, unlike other components, doors are in constant motion, which can cause problems later.

Although a fire door will securely fit its enclosure at the time it is hung, the constant opening and closing of the door weakens the hinges and door closers, making the fit less secure over time. “Doors are the weak link—they’re one of the biggest dangers when it comes to fire risks in a hospital,” Kaiser says. “Not surprisingly, CMS was concerned that hospitals were not maintaining the doors to the degree they needed to be maintained.”


NFPA 80 may contrast with local municipal fire codes, in some cases sharply. Each municipality’s fire code is unique, given the singular nature of the location, such as a dense urban center. Permits for construction and renovations reflect these nuances in the local codes. Consequently, a single health care facility has two sets of rules with which to comply—federal and local.

“A 10-story hospital that is renovating its second floor would need to go to the local municipality and submit the architect’s plans, which are evaluated according to the city’s fire code,” says Kaiser. “In such cases, the city doesn’t care what the NFPA code might be. But the hospital has to care.”

There are other contrasts. For example, municipal requirements for fire walls in which the fire doors reside typically fall under the International Fire Code 703.1. The code, which addresses the ongoing maintenance of a hospital as opposed to new construction, requires a formal inspection by a fire marshal each year. “When you turn to the new CMS code on this subject, the rules are vague, requiring inspection every one to three years,” Kaiser says.

Another complication confronts health care systems with hospitals located in multiple municipalities and states. In one municipality, the facility may be bound by less stringent municipal fire codes from 2006, whereas in another region it may have to comply with a stricter building code from 2009. “The multiplicity of different municipal codes makes it tougher to achieve a consistent approach toward implementation and (regulatory) compliance,” Kaiser says.

Health care facilities should always defer to the highest fire safety standards, he advises. “Err on the side of the most restrictive,” says Kaiser. “If a city does not require a door to be put in a hallway, for instance, but NFPA does require this, then the best practice is to put the door in. If the municipality wants a fire extinguisher positioned every 100 feet and NFPA wants them every 80 feet, position them every 80 feet.”


The new rule places enormous administrative and other burdens on the shoulders of hospital building and maintenance staff. According to Kaiser, a typical 800,000 square-foot hospital has approximately 1,000 fire doors. Under the new CMS requirements, the facility has to conduct a fairly intensive formal 11-point visual and operational test verifying that each door adheres to the NFPA 80 fire code. Among the 11 items in this list are:

  • No open holes or breaks present on surface.
  • Intact glazing in place.
  • Doors, frame and hardware secured and in working order.
  • Door clearances within required specifications.

If the inspection indicates problems that may create a fire hazard, hospitals are required to resolve the issue. “Under the prior CMS standard, it took eight hours to conduct a visual and physical inspection of the doors and barriers,” says Kaiser. “We’ve calculated that it takes about 15 minutes per door to complete the inspection under the new CMS standard. That adds up to 15,000 minutes, or 250 hours. And that’s just for the inspections.”

Thereafter, the facility must address the rule’s reporting requirement—documenting the inspection and follow-up repairs pertaining to each door. “Previously, you could write up all 1,000 doors in a one-page summary,” says Kaiser. “Now you have to respond to each door across the 11 point verification, specifying in writing the steps the hospital has taken or will take to satisfy each point.”

In many cases, this can add up to hundreds of pages, he says, while the repairs “can take months to get all the doors up to snuff.”

For example, the new rule requires that the gaps around a swinging door in a closed position be a maximum of 3/8ths of an inch at bottom and 1/8th of an inch between the door and frame. “In a hospital environment where people are constantly running equipment and carts into the swinging doors, they’re continually out of whack,” Kaiser says. “Maintaining the doors to such high tolerances is a constant battle.” This high volume of traffic also affects the integrity of the door hardware. “A door closer rated to withstand one million cycles may need to be replaced in a year,” he adds.

Many hospitals are finding that the tasks required to address the new regulation are too complex, time-consuming and onerous to handle. In such cases, it may be prudent to outsource the work to experts like Barrier Compliance Services and Grainger.

“We can educate the marketplace about their responsibilities through webinars and our publications and account managers,” says Kaiser. “That’s just the first step and it is highly advisable. But we also offer a turnkey solution in which we will take responsibility for the inspection, repairs, training, and reporting, ensuring compliance.”

With the clock ticking toward the deadline, expert advice may be exactly what is needed.


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