By Brad Keyes / Special to Healthcare Facilities Today

Q: You have stated in previous Q&As that all fire-rated door assemblies must be tested and inspected. I don’t think that is true on fire-rated door assemblies that are not located in a fire-rated barrier. I was under the impression that the hospital’s current Life Safety drawings would be the determining factor on what barriers the hospital was responsible for maintaining. For example, if the building had rated doors on a wall that was not denoted as a fire rated barrier on the LS drawings, one could justify why there were not maintained. I run into the installation of unnecessary rated doors in many facilities, both old and new.

A: You make an interesting case. However, the Life Safety Code always trumps everything else, and in this case it would trump the hospital’s LS drawings. According to 7.2.1.15.2 of the 2012 LSC, it clearly says all fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80. There is no exception for fire-rated door assemblies that are not located in a fire-rated barrier.

My advice is to remove the fire-rated label if the facility is sure the barrier is not a fire-rated barrier.

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.