Q: My hospital is a behavioral health hospital converted from an acute hospital. The doors on patient rooms and mostly all doors in this building are solid core doors....which are fire rated. My office door and most in this wing are also lead lined. We need the solid core doors for the patient rooms due to their behavior....regular doors would be torn up quickly. How do I comply with the new ruling on fire-rated door inspections in this situation?
A: You can do one of two actions:
• You can test and inspect the fire-rated door assemblies on an annual basis in accordance with 220.127.116.11.1 and 18.104.22.168.2
• You can remove the fire-rated label on the door assemblies if the door is not required to be a fire-rated door assembly
Even if the door is a labeled fire-rated door assembly but is located in a barrier that is not required to be a fire-rated barrier, you must still maintain the door in accordance with NFPA 80, which requires annual test and inspection. However, if the barrier is not required to be a fire-rated barrier, and you remove the labels (on the door and on the frame) then the door is no longer a fire-rated door assembly and you do not have to maintain it as such.
Brad Keyes, CHSP, is the owner of KEYES Life Safety Compliance, and his expertise is in the management of the Life Safety Program, including the Environment of Care and Emergency Management programs.
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