55th ASHE Annual Conference & Technical Exhibition 2017
July 15-18, 2018 | Seattle, WA
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Wednesday, May 31, 2017

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Can your team handle the heat of having routine fire door inspections?
You may have heard that the Centers for Medicare & Medicaid Services (CMS) issued New Conditions of Participation that reference NFPA 101® and NFPA 80 requiring routine inspections of fire doors performed by "qualified persons". You don't need to have a special certification or third party training to be qualified, but you do need to be prepared for the unexpected with a well-oiled fire door maintenance program.

Preparing for a fire door inspection
Creating a thorough fire door maintenance program can help keep doors up to code while protecting patients, staff, and health care facility visitors. Take these 4 easy steps to develop a fire door maintenance program for your hospital or health facility.

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Step 1: Take inventory of your facility's fire doors.
Take inventory of all the fire doors that are subject to inspection as required by the codes and standards regulating your facility. You may also want to include other types of doors into your maintenance program. For example, fire and smoke barriers should be part of the door maintenance program, but you may also consider adding patient room doors or others as well.

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Step 2: Prioritize your list of fire doors.
Prioritize fire doors based on their importance. Doors that are in the worst condition or those not up to code and pose the biggest risks should get repaired first. For example, a stairwell fire door that doesn't function properly can be a major hazard to many people and should be a top priority. On the other hand, a patient room door may be lower on the priority list if it is not designed to function as a fire or smoke barrier.

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Step 3: Make the commitment to fix fire door issues throughout your entire facility.
Addressing all door assembly issues at your hospital could take a long time. Make the commitment to managing your fire doors. Remember, fire and smoke doors are an important part of fire protection in hospitals, and you need to find the time and resources to keep doors functioning properly.

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Step 4: Document your fire door maintenance program.
Document your fire door maintenance program. Contact your local authority having jurisdiction or other code officials and show them your plan for maintaining swinging egresses and fire-rated door assemblies. Don't forget – documenting the plan and the work done to fix issues is important for compliance.

How can you get your facility team involved?
Fire door maintenance is not a one-man job. Involving your team will help the implementation phase of your new program run smoothly. You'll want to plan to train your staff and assign tasks across your team.

Here are ways your team could assist in preparing for fire door inspections:

  • Reach out to veteran team members that may have the knowledge and ability to identify certain parts and manuals that may help you find intricate pieces and parts that would otherwise be tough to locate.
  • Have team members assist in collecting technical information to build a library of parts, manuals, and warranty information.
  • Enlist your team to help with building lists of door hardware components that are currently installed on each door assembly. If your building is on the newer side, this hardware set might already exist. Check before creating these lists and you might save yourself time.
  • Ask your team to locate and document all dates of installation to help with warranties. If the only warranty that exists is on the door, make sure to take a picture and keep a copy with all the rest of your warranties. A door warranty could get painted over or removed at any time.
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Taking the next step.
Once your fire door maintenance program is created, it needs to be managed. Continue to collect inventory, prioritize, address issues, and document to keep the doors in your health facility functioning as intended.

ASHE is working on developing a publication and education program related to fire door maintenance. A session at the ASHE Annual Conference, Inspecting and Maintaining Swinging Egress and Fire Doors, will also review safety inspection and testing requirements for swinging doors in NFPA 101 and NFPA 80. Click here to learn more about that session and register for the conference to attend this program.

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