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Assessing fire door maintenance

With the increased scrutiny that Joint Commission

surveyors and CMS state agency inspectors are providing

to fire doors, it is a sure bet that they will find a prob-

lem or two in facilities that have older door assemblies

in fire-rated barriers. Self-assessments for life safety

compliance often suffer from tunnel vision on the as-

sessor’s part, and fire doors in particular are frequently

overlooked.

One of the more common issues with older fire

doors is replacement hardware. Most (if not all) swing-

ing fire-rated doors in healthcare institutions today are

the type that NFPA 80 (Standard for Fire Doors and Fire

Windows, 1999 edition) refers to as “swinging doors

with builders hardware.” This means that the individ-

ual components of the fire door assembly are listed by

an independent testing organization, such as Under-

writers Laboratories (UL) or Intertek, as opposed to the

overall assembly being listed. As such, the “builder”

may select different types of listed components to fit

his or her design parameters. Since the individual com-

ponents are listed, they can be replaced with similarly

listed components (that are not necessarily the same

make or style) as the original components wear out or

fail. As an example, if a fire door assembly is originally

installed with

a Norton door

closer, and some

time later the

door closer fails,

the organization

may replace the

Norton closer

with an LCN

closer as long as the latter is listed for fire-rated door

assemblies.

Sometimes, in fact, it’s necessary to switch component

styles when a device fails. The ori ginal-style devices may

no longer be available, meaning the only solution may

be to install a device of a diffe rent brand. However, door

closers’ mounting hole patterns do not always match

up across brands, which may result in unfilled holes on

the fire door. This scenario is actually quite common for

older facilities.

Naturally, facility managers with this problem often

wonder what to do with the remaining holes in their

fire-rated doors. Until recently, the only option was to fill

those holes with steel fasteners, or fill the screw or bolt

holes with the same material as the door. Now there is

a new product on the market that can easily solve this

problem without resorting to the use of unsightly steel

bolts and nuts.

“We discovered the most common issues with fire

door inspectors were they are finding holes in doors

where hardware was removed,” says Gene Redahan,

vice president of operations for Fire Door Solutions in

Dothan, Ala. “There were either bare holes or some were

IN THIS ISSUE

p. 4 Main drain testIs this test really required? Guest columnist Bryan Galloy, MBA, CSP, CHFM, explores the answer.

p. 6 Addressing bottom rods What should facilities managers know about bottom rods on fire-rated doors? Read more inside.

p. 10 Questions & Answers This month’s Q&A talks about soiled utility rooms, dead bolts on psych rooms, and more.

p. 12 Quick tip This month’s quick tip is a sample tool for addressing main drain testing.

December 2012 Vol. 14, No. 12

The newsletter to assist healthcare facility managers with fire protection and life safety

HealtHcare life Safety compliance

“ We discovered the most

common issues with fire

door inspectors were they

are finding holes in doors

where hardware was

removed.”

—Gene Redahan

Healthcare Life Safety Compliance December 2012

© 2012 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978-750-8400.

filled with wood putty, firestop, or even automotive

body fillers.”

Redahan explains that fire door inspectors were citing

these situations when they found them, but the inspec-

tors had no suggestions on how to repair the doors,

other than steel bolts.

“Upon doing some research, we found there was

nothing out there that had been tested and listed to

be used in that particular application,” says Redahan.

“It certainly makes sense that firestopping sounds like

it would work, because it is able to be used in fire-rated

walls. But there was nothing that had been tested in that

application.”

Redahan saw an opportunity to solve this problem,

and worked with his associates to develop a new style of

firestop caulk for fire-rated doors.

“So what we did, we took the basic firestop and did

our own testing with it and saw that it would hold up

to the heat but would not survive the hose stream test,

which is one of the requirements of NFPA 252,” he

explains. “So we took the firestop formula and tweaked

it and made a few changes here and there, and tested

it again. Once we were able to get past our testing, we

then took it to Intertek and had them test it to be used

in those applications of wood fire doors rated up to

90 minutes.”

Intertek, which also goes by the name of Warnock

Hersey, is an approved testing laboratory, similar to UL,

and tests to the same exact standards as UL does.

“We were tested to NFPA 252 (2012 edition), UL

10C (2009 edition), UL 10B (2009 edition), and CAN

S104 (1985 edition), which is the Canadian equiva-

lent,” says Redahan. “We met all those requirements

for those applications. Our product, as it was applied

in holes up to 3/4-inch diameter in fire-rated doors,

underwent 90 minutes in the furnace with the tem-

peratures mandated by NFPA, and then withstood the

hose stream test, which is also mandated by the same

codes.”

According to product literature, Fire Door Solutions’

caulk is a commercial-quality intumescent, noncombus-

tible fire-, smoke,- and draft-stopping sealant. The caulk

is water-based, can withstand temperatures of 3,000ºF

for up to eight hours, and can be safely removed with

soap and water prior to curing.

Redahan notes that the individual applying the prod-

uct is not required to be certified or licensed.

“NFPA 80 only requires the person making repairs on

fire-rated doors to be knowledgeable,” he says. “We’re

not creating new penetrations; we’re not drilling new

raceways or anything like that. We’re simply doing the

same thing as you would if you’re putting a steel bolt

Managing Editor: Matt Phillion, CSHA [email protected]

Senior Editor: Brad Keyes, CHSPSenior Consultant

Keyes Life Safety

Compliance

www.keyeslifesafety.com

Healthcare Life Safety Compliance (ISSN: 1523-7575 [print]; 1937-741X [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate is $289 for one year and includes unlimited telephone assistance. Single copy price is $25. Healthcare Life Safety Compliance, P.O. Box 3049, Peabody, MA 01961-3049. Copyright © 2012 HCPro, Inc. All rights reserved. Printed in the USA. Except where explicitly encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions or for technical support with questions about life safety compliance, call 781-639-1872 or fax 781-639-7857. For renewal or subscrip-tion information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be in cluded on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of HLSC. Mention of products and services does not constitute endorsement. Advice given is general and based on National Fire Protection As-sociation codes and not based on local building or fire codes. No warranty as to the suitability of the information is expressed or implied. Information should not be construed as engineering advice specific to your facility and should not be acted upon without consulting a licensed engineer, architect, or other suitable professional. Final acceptability of such information and interpretations will always rest with the authority having jurisdiction, which may differ from that offered in the newsletter or otherwise. Advisory board members are not responsible for information and opinions that are not their own.

Editorial Advisory Board Healthcare Life Safety Compliance

Henry KowalenkoSupervisor, Design Standards UnitOffice of Healthcare Regulation, IL Department of Public Health Chicago, Ill.

Peter LeszczakNetwork 3 Fire Protection EngineerU.S. Department of Veterans Affairs West Haven, Conn.

David MohilePresidentMedical Engineering Services, Inc. Leesburg, Va.

James MurphyConsultantThe Greeley Company Danvers, Mass.

Thomas SalamoneDirector of EC and Regulatory ComplianceGannett Fleming Yonkers, N.Y.

William Wilson, CFPS, PEMFire Safety CoordinatorBeaumont Hospitals Royal Oak, Mich.

James R. Ambrose, PETechnical Director, HealthcareCode Consultants, Inc. St. Louis, Mo.

Frederick C. Bradley, PEPrincipalFCB Engineering Alpharetta, Ga.

Michael Crowley, PESenior Vice President, Engineering ManagerRolf Jensen & Associates, Inc. Houston, Texas

Joshua W. Elvove, PE, CSP, FSFPEFire Protection EngineerAurora, Colo.

A. Richard FasanoManager, Western OfficeRussell Phillips & Associates, LLC Elk Grove, Calif.

Burton Klein, PE PresidentBurton Klein Associates Newton, Mass.

December 2012 Healthcare Life Safety Compliance


through the hole. We’re just filling the hole, and there

are no tricks to it.”

Fire Door Solutions also has another product, called

the Thru-Bolt, that fills holes in wood and metal fire-

rated doors.

“The Thru-Bolt is another product that we saw a need

for,” says Redahan. “When we went through hospitals,

we would see bolts used to fill a hole where a closer was

removed. It was unsightly.”

Facility maintenance people were installing bolts,

nuts, and washers in open holes to comply with NFPA

80 requirements. “Aesthetically, it did not look good,”

says Redahan. “They would cut off the excess amount of

the bolt. We decided there needs to be a solution where

you can fill the hole and would be paintable.”

So Redahan and his associates went back to the draw-

ing board to develop a product that could be used by

maintenance staff.

“We designed a stainless steel male/female-type bolt

that screws into itself and is flat on both ends,” says

Redahan. “Once installed in the door, it screws into itself.

It is a much better-looking product.”

According to Redahan, the Thru-Bolt may be used in

steel metal rated doors and is available in diameters up

to 1/2 inch.

Frequent inspections of fire-rated doors will become

a common practice for all hospitals as soon as the 2012

edition of the Life Safety Code® (LSC) is adopted. How

facilities will track those inspections is not stated by the

new LSC, but Fire Door Solutions, along with its part-

ners, has developed a fire door assembly inspection pro-

gram that is automated and entirely cloud-based.

“We noticed a need for affordable inspection

software, not only for fire door inspection companies

but also for facilities that plan to do the inspections on

their own,” says Redahan. “The system is completely

cloud-based, meaning all of the information is stored in

servers online. As long as you have an Internet con-

nection, the program can be accessed from any com-

puter. The software is Android-based and works with a

supplied tablet. The software includes reports that are

available for the [authority having jurisdiction] at any

time. The initial cost of the software includes a tablet,

QR codes, and a year’s worth of support.”

With the pending adoption of the 2012 LSC (see the

November 2012 issue of HLSC for more on this topic),

fire door inspections will require healthcare organiza-

tions to develop a strategy for testing and inspecting their

doors. Specifically, inspections should seek answers to

the following questions:

➤ Are the door and frame free from holes and breaks in

all surfaces?

➤ Are the glazing, vision light frames, and glazing beads

intact and securely fastened?

➤ Are the doors, hinges, frame, hardware, and thresh-

old secure, aligned, and in working order with no vis-

ible signs of damage?

➤ Are there any missing or broken parts?

➤ Is the clearance from the door edge to the frame no

more than 1/8 inch?

➤ Is the door undercut no more than 3/4 inch?

➤ Does the active door leaf completely close when

operated from the full open position?

➤ Does the inactive leaf close before the active leaf

when a coordinator is used?

➤ Does the latching hardware operate and secure the

door in the closed position?

➤ Is the door assembly free from auxiliary hardware

items that could interfere with its operation?

➤ Has the door been modified since it was originally

installed?

➤ If gasketing and edge seals are installed, have they

been verified for integrity and operation? n

Contact Managing Editor Matt Phillion, CSHA

Telephone 781-639-1872, Ext. 3742

E-mail [email protected]

Questions? Comments? Ideas?



Editor’s note: The following article was written by guest

columnist Bryan Galloy, MBA, CSP, CHFM, fire and life safe-

ty manager for MD Anderson Cancer Center in Houston.

An understanding of the intent of NFPA codes and

standards is something a fire safety professional must

possess. In today’s world, where operational and financial

efficiencies are important factors to the E suite, fire safety

professionals must balance the effort needed to perform

required inspections, maintenance, and testing while en-

suring fire safety systems provide their designed life safety

protection without fault. This article will discuss how

main drain tests in most high-rise buildings that have

combined sprinkler/hose standpipe systems with large

supply pipes (6 inches diameter or greater) may not be as

effective of a test as the writers of the standards intended.

For systems connected to a fire pump that is fed from a

supply tank (which, in turn, is automatically refilled by a

municipal water supply), main drains provide no added

assurance of the system’s reliability.

A safety professional once told me, “NFPA codes and

standards are written with words, and words have mean-

ings.” So, to eliminate any confusion over the meaning

of critical terms discussed in this article, I will rely on the

definitions published in the 2010 edition of NFPA 13,

Standard for the Installation of Sprinkler Systems; the 2010

edition of NFPA 14, Standard for the Installation of Stand-

pipes and Hose Systems; and the 2011 edition of NFPA 25,

Standard for the Inspection, Testing, and Maintenance of Water-

Based Fire Protection Systems. A main drain is defined in

section 3.3.7.1 of NFPA 25 as the primary drain connec-

tion, which is located on the system riser and is also uti-

lized as a flow test connection. System risers are not de-

fined in NFPA 25, but NFPA 13, section 3.5.12 gives this

definition: “[t]he above ground horizontal or vertical pipe

between the water supply and the mains (cross or feed)

that contains a control valve (either directly or within its

supply pipe) and a water flow alarm device.” Finally, a

standpipe is defined by NFPA 14 as “[t]he system piping

that delivers the water supply for hose connections, and

for sprinklers on combined systems, vertically from floor

to floor.”

So where and when is a main drain test required? The

answer is found in NFPA 25, section 13.2.5, which states:

“A main drain test shall be conducted annually at each

water-based fire protection system riser to determine

whether there has been a change in the condition of the

water supply piping and control valves.”

Furthermore, section 13.3.3.4 states, “a main drain

test shall be conducted any time the control valve is

closed and reopened at system riser.”

The NFPA handbook for the 2011 edition of NFPA

25 clearly addresses the intent of a main drain test in its

commentary. The handbook states:

The two major reasons to conduct a main drain test are to

verify the following:

1. Water supply pressure is similar to the original

acceptance test or to other previous tests.

2. The system control valve is fully open after having been

closed and reopened during annual testing. Main drain

test results should not be solely relied upon to determine

whether valves are open. A main drain test may not re-

veal a partially closed valve in a large-diameter supply

pipe with relatively high pressure.

With all this being said, a fire sprinkler system and/

or a hose standpipe system connected directly to the

municipal water supply relies on municipal water pres-

sure and must adhere to the requirements of the NFPA

25 main drain test. Conducting a main drain test is not

strictly done to verify the proper operation of valves

inside of a building, but to verify the operation of valves

within the municipal water supply outside of the build-

ing’s control. Indeed, there have been numerous cases

where the supply of water from the local municipality

was impaired due to a partially closed or faulty control

valve. The main drain test will ferret out those deficien-

cies before a tragedy occurs.

Is the main drain test really required?



Water-based fire protection systems are usually tied into

the same city water mains that provide domestic water to a

building. If a municipal water department worker un-

knowingly leaves a valve partially closed after repairing a

leak down the street, this may result in low domestic water

pressure throughout the entire building. But without a

main drain test, low domestic water pressure alone may

not always alert the organization to a problem with water

supply to the automatic sprinkler and standpipe system.

When a main drain test indicates a water supply prob-

lem, the issue can be reported to the municipality and

typically resolved quickly. A reduction in water pressure

to a low-rise building will typically be discovered by

building occupants due to the unavailability of domestic

water long before an annual main drain test indicates a

problem. But with a high-rise building that has booster

pumps on the domestic water supply, a partially closed

valve in the street may not always be noticed.

A direct connection to the municipal water supply

is not the only configuration for water-based fire

protection systems. Depending on the size of the system

and the water supply required to operate the system

effectively, a fire pump may be required to enhance

the pressure provided by the municipal water system.

Varying local municipal codes dictate the connection of

the fire pump to the municipal water system. For exam-

ple, the city of Houston prohibits the direct connection of

a building fire pump to its water supply system. The fire

pump suction line must be connected to a water storage

tank, which is automatically refilled from the municipal

water system. Thus, the fire pump is effectively fed from

a tank, rather than from the city water mains.

In my opinion, choosing not to conduct a main drain

test in a system where the fire pump water supply is

from a tank and not a municipal water main does not

leave that system in jeopardy of performing improperly.

But remember, NFPA 25 appears to be all about “belts

and suspenders,” meaning its authors are being conser-

vative, cautious, and redundant.

The annual fire pump flow test and the analysis of

the pump curve constructed by the results of the flow

test will verify the current pressures and water flow

rates as they relate to the original acceptance report and

previous fire pump flow tests. This fire pump flow test,

like the main drain test, is a form of verifying the water

supply.

As for the second reason for conducting a main

drain test, NFPA 13 and the Life Safety Code® require

all valves in water-based fire protection systems to be

electronically supervised with tamper switches con-

nected to the building’s fire alarm system. NFPA 25

requires the tamper switches on the control valves to

be tested semiannually and visually inspected monthly.

In addition, valves within a water-based fire protec-

tion system must be of the indicating type, therefore

easily identified as open or closed during the monthly

inspections.

In conclusion, it appears to me that the main drain

test is an overly conservative and redundant approach

to water-based fire protection system maintenance,

inspection, and testing. The two reasons identified in

the NFPA 25 handbook for conducting a main drain

test are valid: The test identifies a failed or inefficient

supply of water for a water-based fire protection sys-

tem directly fed from a municipal water supply. How-

ever, as previously discussed, annual fire pump flow

tests, monthly visual control valve inspections, semi-

annual control valve tamper switch testing, quarterly

fire department connection inspections, water sup-

ply tank level inspections and monitoring, pressure

gauge calibration or replacement, and annual sprinkler

inspections all ensure that the water-based fire protec-

tion system as a whole operates as designed. By testing

and inspecting all of these components at a frequency

similar to or greater than a main drain test, a reason-

able conclusion can be drawn that the main drain test

is unnecessary and redundant. n

Editor’s note: Readers are reminded that current NFPA

codes and standards, which are enforced by all of the national

accreditation organizations, still require annual main drain

tests. See page 12 for a sample test form.



Fire-rated doors in healthcare organizations come

with different configurations of fire-rated hardware. One

of the more common configurations is latching hardware

that is mounted on the surface of the door, rather than

inside the door. While this configuration is popular be-

cause it is considered easier to adjust and maintain than

concealed rods, it leaves the rods exposed between the

horizontal panic hardware and the latching device at the

top and/or bottom of the door. Facility managers quickly

learn that the bottom rod extending to the lower part

of the door is a frequent target of carts, beds, and other

items that are pushed through the opening.

“Vertical rod fire exit hardware is available with top

and bottom rods and latches, or with the top rod and

latch only, known as ‘less bottom rod’ or LBR devices,”

says Lori Greene, manager of codes and resources at

Ingersoll Rand Security Technologies.

Eliminating the bottom rods and latches can help

to meet accessibility requirements and also allows the

floor strikes to be omitted; however, if the fire door

hardware is listed for use with bottom rods and latches,

then removing them after they have been installed

may require the installation of a retrofit kit or other

modifications.

“LBR devices have been available from most panic

hardware manufacturers for many years, but I still

receive questions about them regularly—either related to

the use of the product on fire doors or their installation

in a means of egress,” says Greene. “NFPA 80, Standard

for Fire Doors and Other Opening Protectives (2010 edition),

does not specifically address LBR fire exit hardware.”

NFPA 80 requires fire doors to be equipped with an

active latch bolt to ensure that the door is positively

latched during a fire. Panic hardware used on fire doors

must be fire exit hardware, which is not equipped with

the mechanical means to hold the latch retracted (aka

“dogging”) and must bear labels from the listing agency

for compliance with both panic and fire test standards.

If dogging is desired for fire exit hardware, it must be

an electric function that automatically provides positive

latching upon a fire alarm.

LBR fire exit hardware has been successfully tested for

use on fire doors, and the specifics can be found in the

manufacturer’s literature or the listing agency’s directory

of certified products, according to Greene. For most

applications, an auxiliary fire pin is required in order for

the doors to maintain their fire resistance rating. This pin

typically mounts between 6 and 12 inches above the floor,

on the edge of the door; however, some manufacturers

have tested their LBR devices without an auxiliary fire pin,

or with pins mounted in the bottom edge of the door.

The pins remain retracted under normal conditions,

and are heat actuated. When the temperature of

activation is reached—usually around 400ºF at the

location of the pin—the pin projects from the edge of

one door into a hole in the edge of the other door leaf

(or into the floor if the pins are installed on the bottom

of the door). In addition to fire exit hardware, these

auxiliary fire pins are sometimes used on fire doors with

automatic flush bolts where the bottom flush bolt is

omitted.

“The auxiliary fire pin has raised concerns regarding

egress in the past, because once the bolt is projected,

the doors no longer allow free egress,” says Greene. “It’s

important to understand that the pin projects only dur-

ing a fire, and its purpose is to maintain the alignment of

the doors to prevent the spread of smoke and flames.”

According to Underwriters Laboratories (UL), an aux-

iliary fire pin with an activating temperature of 400ºF

typically projects 15–20 minutes into a fire test, when

the temperature inside the test furnace is approximately

1,400ºF. The pin is only actuated when the activation

temperature is reached, and at that point the area would

not be tenable for occupants or firefighters, according to

Greene.

The tests used for fire door assemblies (UL 10B, UL

10C, and NFPA 252) do not require the doors to be oper-

able at the conclusion of the test. Most locks and exit

‘Less bottom rod’ fire exit hardware



devices incorporate fusible links that render the hard-

ware inoperable during the fire test, so the doors remain

latched throughout the hose stream portion of the test.

The auxiliary fire pin associated with LBR exit devices

operates under the same principle.

“Another issue that has been raised regards firefighter

access once the auxiliary fire pin has been projected

after reaching the activating temperature,” says Greene.

“In addition to the fact that most latching hardware is

designed to become inoperable during a fire, the doors

themselves (especially steel doors) are likely to become

wedged into the frame. The intumescent material

required in some applications may also affect the opera-

tion of the door after a fire. Firefighter access will likely

require a sledgehammer and axe, even if an auxiliary

fire pin is not part of the assembly.”

While this newsletter typically deals with require-

ments involving the Life Safety Code®, many healthcare

facilities are also required to comply with their local and

state building codes, which is often the International

Building Code (IBC). A change to the 2009 edition of the

IBC helps to clear up some of the confusion about the

egress requirements when the above-mentioned prod-

ucts are used on fire doors, according to Greene. Para-

graph 1008.1.9, Door Operations, states that you must

be able to readily open egress doors from the egress side

without the use of a key or special knowledge or effort,

except as permitted by this section of the code. Paragraph

1008.1.9.3, however, lists several exceptions where locks

and latches shall be permitted to prevent operation of

doors. These exceptions include:

➤ Places of detention or restraint

➤ Certain occupancies where key-operated locks may

be used on the main entrance if certain criteria

are met

➤ Pairs with automatic flush bolts, with a requirement

for the inactive leaf to be without hardware that

would give the impression that the inactive leaf could

be operated independently

➤ Dwelling unit doors in Group R occupancies with an

occupant load of 10 or less, where a night latch, dead

bolt, or security chain may be used in addition to an-

other latching device

And Greene notes the presence of a new exception,

which was added in the 2009 edition of the IBC: “Fire

doors after the minimum elevated temperature has

disabled the unlatching mechanism in accordance with

listed fire door test procedures.”

“The purpose of this last exception is to address the

use of fusible links and heat-actuated components used

in door hardware, including the auxiliary pin used with

less bottom rod fire exit hardware,” she says.

Before removing bottom rods and latches from

existing fire exit hardware, it’s important to check

with the manufacturers of the fire exit hardware and

the fire doors, and to follow the required procedures.

Retrofit kits are available for some brands of hardware,

and the kit may include replacement top strikes that

need to be installed. Removing existing rods and

latches without following the proper procedures is

likely to result in a fire door assembly that is no longer

code-compliant.

Openings in the outer casing of the horizontal

hardware on the door and floor-mounted recesses for

latches can easily provide surveyors and inspectors a

clue as to whether a lower bottom rod was originally

specified by the manufacturer. If they notice these

clues, they may very well ask to see documentation

from the manufacturer authorizing the removal of the

lower bottom rods. Without this documentation, you

are vulnerable to a citation. n

If it’s been more than six months

since you purchased or renewed your

subscription to HLSC, be sure to check

your envelope for your renewal notice or call customer

service at 800-650-6787. Renew your subscription early

to lock in the current price.

Don’t miss your next issue!



Nearly every acute care hospital in the United States

has horizontal sliding doors, most of them with glass

panels. These doors can be found in various locations

around the hospital, but regardless of location they have

one basic characteristic in common: They are all installed

in a means of egress.

The Life Safety Code® (LSC) permits horizontal sliding

doors in the means of egress provided they meet certain

requirements. For example, the doors must be operable

from both sides; the force needed to operate the doors

must not exceed a certain maximum amount; the doors

must break away and swing in the direction of egress;

and if installed in a corridor, the doors must latch and

resist the passage of smoke. They also must meet fire

door requirements if located in a fire-rated barrier,

which means the door itself must be fire rated, and self-

close and latch on a fire alarm signal.

While a basic glass panel sliding door does not qualify

as a fire-rated door, there is at least one manufacturer

that makes horizontal sliding doors that are fire rated:

Won-Door Corporation, located in Salt Lake City. Won-

Door’s FireGuard door is the original horizontal sliding

fire door assembly and carries a fire rating of up to 90

minutes. It is universally accepted as a wide-span open-

ing protective regardless of occupancy type and with no

occupant load limit. These types of doors are frequently

found in healthcare occupancies, especially where wide

corridors are desired without the restrictions created by

swinging door assemblies.

But what is frequently found in hospitals, especially in

ICUs or ERs, are aluminum-framed, glass panel non-rat-

ed horizontal sliding doors. These sliding glass doors may

come in a two-panel or a three-panel configuration and

are very popular with designers and staff alike. It is easy

to understand why they are so useful in the healthcare

setting—the clear glass allows direct supervision from

a nurses’ station into the room even with the door in a

closed position. In addition, the larger opening allowed

by the sliding panels (or leafs, as the LSC refers to them)

permits beds to be rolled into and out of the room much

more easily.

What is not as clearly understood is why designers

actually specify a three-panel horizontal sliding door in

these applications. A three-panel sliding door has one

stationary panel and two moving leafs. While these

doors function well, they are not permitted according to

the healthcare occupancy chapters of the 2000 edition

of the LSC. Sections 18/19.2.2.2.9 specifically state that

if a horizontal sliding door is not automatic closing, it

is limited to a single leaf, not two. The typical sliding

glass doors in ICU and ER patient rooms are not usually

automatic closing, so they would be limited to just one

moving leaf.

However, this doesn’t seem to stop designers from

specifying three-panel sliding glass doors in new con-

struction or renovation applications for healthcare insti-

tutions. One explanation for this conflict may be due to a

change in the 2006 edition of the LSC, which essentially

does away with the single-leaf limitation when the door

serves an occupant load of fewer than 10 individuals.

Could the designers be using the wrong edition of the

LSC when they specify these three-panel doors? Who

knows, but that may be one explanation for this code

violation.

But more importantly, what do the major national

accreditors say about three-panel horizontal sliding doors

with two moving leafs?

“We expect our accredited organizations to comply

with all of the requirements of the 2000 edition of the

Life Safety Code,” says Joseph Cappiello, chief operat-

ing officer for the American Osteopathic Association’s

Healthcare Facilities Accreditation Program (HFAP). “We

do not single out certain sections of the code to overlook.

Manual horizontal sliding doors with more than one

moving leaf are not permitted in the means of egress.

That includes patient room doors. We have cited this

issue when we observe it, and we will continue to cite it

until the code is changed.”

Horizontal sliding door limitations



Cappiello makes a good point about a change in the

Code. If and when CMS decides to adopt the 2012 edi-

tion of the LSC, it will have the exception for multiple

moving leaf doors in applications with fewer than

10 occupants. As yet, though, CMS has only stated that

it will consider adopting the 2012 edition. The review

process takes years, and a formal statement announcing

the adoption of the new edition is not expected for an-

other two years or so.

CMS does not make formal statements or interpreta-

tions very often—and never in a timely fashion!—but

one indivi dual who is close to the CMS office in Balti-

more says he expects the CMS state agency surveyors

to cite any manually operated sliding doors with more

than one moving leaf since this represents a violation

of the 2000 edition of the LSC. The same individual also

says he thinks CMS would accept a waiver for any doors

cited as such, but they must first be cited before the

agency will consider a waiver.

“We try to call the plays by the book,” says Randy

Snelling, chief physical environment officer at Det

Norske Veritas (DNV) Healthcare, Inc. “We require our

surveyors to apply the 2000 edition of the Life Safety

Code. I don’t see how this issue would be any different.

The surveyor finding is just the beginning of the correc-

tive action. The real action is in the details of an appeal

or corrective action.”

Efforts to receive an official comment from The Joint

Commission’s Standards Interpretation Group went

unanswered by presstime, but an unofficial comment

from the accreditor indicates it too would cite this issue

since it is an LSC requirement.

So what do you do if you discover you have noncom-

pliant manually operated horizontal sliding doors with

more than one moving leaf? Most of the accreditation

organizations above would recommend that you do not

remove them, but either submit an equivalency for their

approval, or submit a waiver request if they are cited—in

other words, don’t spend the money to fix the problem

because in a few short years, the 2012 edition of the LSC

(assuming its adoption) will permit them.

You would need to self-identify the deficiency and im-

plement appropriate alternative life safety measures, ac-

cording to your policy. The Joint Commission will most

likely accept a traditional equivalency for the deficiency

of having more than one moving leaf in a horizontal

sliding door. The traditional equivalency is a written

statement from a registered architect, a professional fire

protection engineer, or a local authority on fire safety

stating that, in the expert’s opinion, the deficiency is

not unsafe or does not pose a threat to the safety of the

patients or staff. This written statement would normally

be based on the presence of additional life safety features

which are not required, such as smoke detectors.

HFAP and DNV would accept a Fire Safety Evaluation

System (FSES) equivalency, which is based on NFPA

101A, Guide on Alternative Approaches to Life Safety (2001

edition). This entails a bit more legwork and a review

of every smoke compartment in the facility. But once

accepted, the FSES is good for the life of the facility or

until such time the area undergoes new construction or

renovation.

If cited by an accreditor during a survey, it is recom-

mended that a waiver request be made as part of your

Plan of Correction, through the accreditation organiza-

tion to the CMS regional office. The three accreditation

organizations are not allowed to grant waivers for LSC

deficiencies; only the CMS regional office is permitted

to approve waivers. This way, the waiver is valid until

the next triannual inspection, when it should be cited

again. Unlike equivalencies, waivers have to be renewed

frequently, but it’s not that long until the 2012 edition of

the LSC will probably be adopted. n

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&AnswersQuestions

Editor’s note: Each month, Senior

Editor Brad Keyes, CHSP, consultant

for Keyes Life Safety Compliance, answers

your questions about life safety compli-

ance. Our editorial advisory board also

reviews the Q&A column. Follow Keyes’ blog on life safety at

www.keyeslifesafety.com for up-to-date information.

Ambulatory care soiled utility room

Q We have an ambulatory care occupancy that has

clean supply and soiled linen rooms. Since these

rooms are considered storage with combustibles, the

Life Safety Code® (LSC) views them as hazardous areas.

These rooms are sprinklered, which means they do

not need one-hour rated barriers. Do these rooms re-

quire doors that need to latch? It does not appear so,

as I read the LSC.

A You’re right. A soiled utility room in an ambu-

latory care occupancy that is protected with

automatic sprinklers does not require fire-rated walls

and no doors are required. It sounds strange, but this

is why: Section 21.3.2 of the 2000 edition of the LSC

refers to section 39.3.2 for protection from hazards,

which identifies storage rooms as hazardous rooms

that need to comply with section 8.4. This section al-

lows the option of sprinklering the room or providing

one-hour fire-rated walls. If you choose the one-hour

fire-rated walls, then you would have to provide a

3/4-hour fire-rated door and frame that self-closes

and positive latches. But in your scenario, your clean

supply and soiled linen rooms are sprinklered, and

8.4 does not require self-closing and latching doors.

Also, section 21.3.6 says there are no requirements

for corridors, so that means there are no require-

ments for corridor doors. This is quite different from

a healthcare occupancy, which would require self-

closing and latching doors even if the rooms were

sprinklered.

Dead-bolt locks on psychiatric rooms

Q In a psychiatric hospital ER, are patient holding

rooms allowed to have dead bolts on the corridor

side with no thumb latch on the inside of the room?

Our administrator’s position is that those rooms can

be used as seclusion rooms at any given time. Is that

acceptable?

A Interesting question. I would say it depends if

the seclusion rooms would only be used for the

purpose of securing individuals who present a threat

to themselves or others. This is commonly called “clin-

ical needs” and is allowed under section 19.2.2.2.4,

exception number 1 of the 2000 edition of the LSC.

However, if the same rooms are used for non–behav-

ioral health patients, then the locks would not be per-

mitted. Section 7.2.1.5.4 does not allow more than

one action to operate a door in the path of egress,

and a dead bolt and a door latch would be more than

one operation. Can you guarantee these rooms would

never be used for anything other than seclusion? If

not, then I would think most authorities would have a

problem with the dead-bolt locks. This situation is go-

ing to end up requiring an interpretation from an au-

thority having jurisdiction (AHJ). The average hospital

has five or more AHJs, and even if four of those AHJs

don’t have a problem with the locks, if the fifth AHJ

does, you’ll have to remove them. Most hospitals deal



with this issue by having sitters watch the patient.

It’s not the best solution, but it does meet the code

requirements.

Closures on inactive door leafs

Q A consultant has mentioned that several of our

doors to hazardous areas are noncompliant. The

door configuration is such that there is a normal 3-by-

4-inch door paired with a small, inactive leaf about 1

by 7 inches. The inactive leaf has an automatic flush

bolt but is not provided with a self-closer. I realize

that hazardous rooms need self-closing, positively

latching doors under the new construction healthcare

occupancy requirements, but I cannot find any discus-

sions on inactive leafs. My question to you is do you

know of any requirements where the configuration I

described would be allowed?

A Section 8.2.3.2 of the 2000 edition of the LSC re-

quires fire doors to be in compliance with NF-

PA 80, Standard for Fire Doors and Fire Windows (1999

edition). Section 2-4.4.5 discusses the requirements

for an inactive leaf in a room which is not occupied

by people. The exception to this section of the code

specifically states that self-closing devices on the in-

active leaf are not required. The caveat in this excep-

tion is the phrase “where acceptable to the authority

having jurisdiction”—meaning the interpretation is

subject to the AHJ’s whim. So, if you ever get an AHJ

that does not permit it, you’re out of luck, but you

could proceed with the conditions of the exception

until such time as an AHJ says you can’t. As far as I

know, The Joint Commission and CMS are in agree-

ment with this exception.

Oxygen cylinders

Q Several of our departments have stretch-

ers with onboard E-size oxygen cylinders. Can

these be considered in use and not count against

the smoke compartment’s 300-cubic-foot limit? Also,

our nursing staff currently checks oxygen inventory

daily and documents it on a log. Is this a written code

requirement?

A Yes and no. All O2 cylinders that are mounted

on gurneys, wheelchairs, and medical equip-

ment but are not actively used by patients are con-

sidered by CMS to be in use, and therefore are not

subject to the 300-cubic-foot threshold for stored

medical gas cylinders. CMS explained its position on

this issue in a memorandum called S&C-07-10, dat-

ed January 12, 2007. The Joint Commission has en-

dorsed this position as well and has said as much on

various occasions. In regard to the nurses checking

oxygen levels on a daily basis, I am not aware of any

LSC or Joint Commission requirement for this ac-

tion. Perhaps your state has something relevant to say

about it. I do know that plant operators frequently

record the level of liquid oxygen in the bulk storage

tanks, but that is more for tracking purposes and to

ensure the oxygen does not run out.

Signs on fire-rated doors

Q Are signs permitted on fire-rated doors? We

posted a sign on a fire-rated stairwell door that

instructed our staff to temporarily not use the door,

and a surveyor said we are not allowed to do this. Is

this true?

A You may have a legitimate appeal on this issue.

Section 8.2.3.2 of the 2000 edition of the LSC re-

quires compliance with NFPA 80, Standard for Fire Doors

and Fire Windows (1999 edition). Section 1-3.5 of NFPA

80 permits you to post signs on a fire-rated door as long

as the sign does not exceed 5% of the total surface area

of the door and does not interfere with the operation of

the door. The sign must be attached with adhesives, not

nails or staples. n



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Quick tip

Main drain test

Locations of

Main Drain Test

Results of this

Main Drain Test

Results of

Previous Main Drain Test

Comparison

Acceptable?

Static Residual Time Static Residual Time Yes No*

*All ‘No’ answers must be investigated and documented with work orders.

Annual Test or After a Control Valve Has Been Closed and Reopened

Date of test: Work order #: __________________________________Signature of technician(s): _________________________________________________________________________ Date of previous main drain test that this test is compared to: __________________________________________ Name of building where main drain is being tested: ___________________________________________________ Prior to testing, has the fire alarm monitoring entity been notified of the test? _____________________________ Has the fire alarm system been programmed not to activate the alarm? __________________________________ Has the fire pump been shut off, but the jockey pump left on? _________________________________________ If the fire pump is off for more than four hours in a 24-hour period, has the local fire department been notified and a fire watch been implemented? __________________________________________________________ Directions:1. Record static pressure2. Open main drain test valve and allow water to flow3. After water flow has been stabilized, record residual pressure4. Close main drain test valve slowly 5. Record time required to restore water pressure back to static pressure6. Compare results of this test to previous main drain test results for abnormalities

Source: NFPA 25, 1998 edition

1. (T) (F) “Swinging doors with builders hardware” means the individual components of the door assembly are listed by an independent testing laboratory.

2. (T) (F) According to Gene Redahan, the most common issue with fire door inspection is malfunctioning hardware.

3. (T) (F) Intertek is an approved testing laboratory, similar to Underwriters Laboratories (UL), that tests to the same exact standards as UL does.

4. (T) (F) According to guest columnist Brian Galloy, MBA, CSP, CHFM, the NFPA 25 main drain test is an overly conservative and redundant approach to water-based fire protection system maintenance.

5. (T) (F) Removing the bottom rod and latches for surface-mounted hardware on fire-rated doors may be permitted based on the manufacturer’s instructions.

6. (T) (F) After an auxiliary fire pin is activated in a fire-rated door, it is still expected to be operable for firefighters’ use.

7. (T) (F) Automatic closing sliding glass doors are frequently found in ICU and ER patient rooms.

8. (T) (F) The formal announcement of CMS’ adoption of the 2012 edition of the Life Safety Code® is expected in two years or so.

9. (T) (F) A soiled utility room in an ambulatory care occupancy that is protected with sprinklers is required to have fire-rated walls and doors.

10. (T) (F) All oxygen cylinders mounted on gurneys and wheelchairs must be counted as being in storage.

QuizQuizHealtHcare life Safety complianceThe newsletter to assist healthcare facility managers with fire protection and life safety

Vol. 14 No. 12December 2012

Quiz questions December 2012 (Vol. 14, No. 12)

A supplement to HealthcareLifeSafetyCompliance

1. True.

2. False. The most common issue is the discovery of holes in doors where old hardware has been removed.

3. True.

4. True.

5. True.

6. False. The auxiliary fire pin will project into the other door leaf when the temperature of the pin inside the door reaches 400°F; at this point, the temperature outside the door would be around 1400°F, an unsurvivable environment for any firefighter.

7. False. Manual, not automatic, sliding glass doors are frequently found in ICU and ER patient rooms.

8. True.

9. False. Fire-rated walls and doors are not required in an ambulatory care occupancy soiled utility room that is protected with sprinklers.

10. False. Oxygen cylinders mounted on gurneys and wheelchairs are counted as being in use, not in storage.

Quiz answers December 2012 (Vol. 14, No. 12)

Copyright 2012 HCPro, Inc. Current subscribers to HealthcareLifeSafetyCompliance may copy this quiz for use at their facilities. Use by others, including those who are no longer subscribers, is a violation of applicable copyright laws. ® Registered trademark, the National Fire Protection Association, Inc.

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