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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 email.

If you were unable to access the handouts to

print, please contact the Association at

614/436-4154 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: 614-436-0939).

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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.

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 614-436-4154.

• You will enter all participants names at one time. Follow the on screen

instructions.

• You will receive an email 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.

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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

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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 long-

term 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

2000-2012 Life Safety Code Guidance as well as authoring Life Safety Code Essentials

for Skilled Nursing Facilities' ECSG, 2012.

Critical LSC Inspections – Doors, Sprinklers, Electrical

KENN DAILY, LNHA

KENN@QISSURVEY.COM

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NFPA

Codes adopted effective July 5, 2016

101 Chapter 19 – Existing

101 Chapter 18 -New Facilities

Reference CodesNFPA 10 – Fire Extinguisher – 2010NFPA 13 – Sprinklers – 2010NFPA 25 – Sprinkler Testing – 2010NFPA 70– Electrical – 2009NFPA 72 –Fire Alarm - 2010NFPA 80 – Fire Doors – 2010NFPA 105 – Smoke Doors – 2010 NFPA 220 – Construction - 2010NFPA 96 – Range Hood – 2011NFPA 110 – Generators - 2011

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Doors

NFPA 80Standard 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.

(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.

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Standard for Fire Doors

5.2.4.2 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.18/19.2.2.5.1

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Signs on Fire DoorsThere 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 4.1.4 of NFPA 80

Fire-rated Door Clearances

6.3.1.7.1 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.

6.3.1.7.2 Clearances shall be measured from the pull

face of the door(s).

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Clearances Under Doors

Swinging Doors with Builders Hardware

Maximum Clearance of 3/4” Under Door Bottom [4.8.4.1]

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

4.1.3.2, 4.1.3.3 and 4.1.3.4

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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

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Basis of Requirements

NFPA 101 requires annual fire and smoke door inspections (Section 18/19.2.2.2.1) which then requires compliance with Section 7.2.1 which includes 7.2.1.15.2

Section 7.2.1.15.2 requires compliance with:

◦ NFPA 80, Standard for Fire Doors and Other Opening Protectives – 2010 Edition

◦ Section 5.2.1 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 7.2.1.15.2 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

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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 18/19.2.2 through 18/19.2.11.

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.

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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 frameNo signs of damage to the door, frame, hinges, and hardwareNo parts are missing or brokenDoor clearances are appropriateSelf-closing device operating properlyIf installed, the coordinator is working Latching hardware operatesNo auxiliary hardware installed that would interfere with operationNo field modifications that would void the labelGasketing and edge seals, if required, are inspected

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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 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.

Fire-rated Doors

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• 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

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Door Label

Fire rated permanent label attached and readable.

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NFPA 80 Annex

NFPA 80 annex note (addition information which is not enforceable (A.8.3.3.2.3), “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

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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 101 8.3.3.1

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Fire Exit Hardware

When fire doors are labeled requiring Fire ExitHardware, ensure labels on the hardware match thelabel 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 theNFPA claims to be themost common failure of fire doors during an actual fire.

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• 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, non-

working 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.

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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.

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Completing Inspection

Facility_______________________________

Tester Name__________________________

Date_________

Door Type: Fire Smoke

Rating _____________________________

Location _____________________________

LocatingFire/ 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.

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Filling Out Inspection

Operationr Swings freelyr Closes properly r Latches properly r Other _______________

Framer Label present and legible r Is securer No open holes/breaks r Frame not rusted throughr Gaskets intactr 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 Closerr All hardware installed r Strike in good shaper Securely installedr Other __________________

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Filling Out Inspection (cont.)

Hinges r Correct r Securely installedr Other ______________

Flush Bolts r Correct r Securely installed r Other ______________

Lockset / Hardware r All hardware installed r Strike in good shaper Securely installedr Coordinator working properly r Other ______________

Fire Exit Hardwarer All hardware installed r Strike in good shaper Securely installedr Other ______________

Otherr No items that interfere installedr No non-compliant field modificationr 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.

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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, 10.5.2.1

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.

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Testing & InspectionReceptacles – 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.

6.3.4 (NFPA 99)

Testing of Electrical Outlets

NFPA 99 6.3.3.2 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

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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.

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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

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Kenneth Daily, LNHAElder Care Systems Group

kenn@qissurvey.com

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