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Check powered fire doors after CMS, TJC offer new info on door-closing devices


May 1, 2018

After the newest clarification on fire doors from CMS and revisions to The Joint Commission’s (TJC) Life Safety standard on providing building features to protect against fire and smoke hazards, it is recommended that healthcare facilities examine all automatic door arrangements.

For the most part, the revision and clarification do not change the requirements for hospital fire doors that have been in place for some time, notes Brad Keyes, senior consultant for Keyes Life Safety Compliance and the former engineering advisor for the Healthcare Facilities Accreditation Program (HFAP).

“The corrections that The Joint Commission is making to their EP just brings them up to speed with what’s been required for years — even decades,” says Keyes.

Change for doors in existing buildings
The change is to LS.02.01.30, EP 13 and specifically adds that positive-latching hardware is among the requirements for corridor fire doors in existing buildings. EPs elsewhere, including those discussion requirements for doors in new buildings, already have the “positive-latching hardware” language.

However, the change also deletes a sentence that said devices that can apply at least 5 foot-pounds of force to keep a door closed in the event of a fire were acceptable for existing doors, and replaces that with two new notes, only for hospitals that use TJC for deemed status. Those notes go into detail about when it is OK to use the closing devices on powered corridor doors.

The note states that doors that do not have positive-latching hardware, which has long been a sticking point with CMS, can use the door-closing devices as long as the hospital can show that the manufacturer does not offer an option to install positive-latching hardware.

TJC’s revision comes two months after the American Society for Healthcare Engineering (ASHE) told its members that it had received clarification from CMS on what the federal agency expected in regard to the door-closing devices.

ASHE gets clarification from CMS
In ASHE’s Health Facilities Management magazine, Chad E. Beebe, AIA, CHFM, CFPS, CBO, FASHE, ASHE’s deputy executive director, said that members had reported that some surveyors seemed to think the devices were prohibited along with roller latches.

“In ASHE's communication with CMS, the organization has determined that this is not the case. The adoption of the 2012 Life Safety Code does prohibit the use of roller latches. However, mechanisms used to maintain a door-closing force of 5 pounds are still allowed in certain cases per the Life Safety Code,” noted Beebe.

He also provided a link to a PDF showing how the LSC would be amended if it were to use CMS requirements.

“It is important to note that CMS’ original objection to roller latches isn’t based on the notion that a 5-pound, closing-force requirement for latches is inadequate, but rather that it is difficult to maintain the 5-pound closing force,” wrote Beebe. “ASHE supports the prohibition of roller latches in healthcare. Although they are advantageous in some situations, the group states that the long-term maintenance and risk of doors opening during a fire event typically outweigh the convenience of the devices.”

This clarification comes about six months after CMS published its own clarification on annual testing and inspection expectations, in S&C 17-38-LSC, to its own state and regional surveyors.

What does this mean for you?
In light of the TJC changes, review all of your automatic door arrangements, as well as any fire-rated doors for which you have used the devices that otherwise require positive-latching hardware, advises Steven A. MacArthur, a senior consultant with The Greeley Company in Danvers, Massachusetts.

“It is possible that not all of their automatic doors will require modification,” notes MacArthur — for instance, the doors in question may already achieve positive latching when the fire alarm is activated, or the doors are located in partitions that would not require positive latching. “But if they haven’t assessed their doors for this during the initial annual inspection of doors, then they need to get going on it.”

Remember that if you are cited for having the wrong type of hardware or door, you will have 60 days to come into compliance, so it is a smart strategy to start looking for those problems yourself as part of regular maintenance activities, says MacArthur.

If you do have to replace or upgrade a door, expect it to be expensive. “This is going to impact folks with improperly configured automatic doors, particularly in areas designated as suites, as well as areas that are equipped with automatic doors that are secured with magnets,” says MacArthur.

The magnets are designed to drop out when the fire alarm is activated, at which point the doors would need to positively latch, and that hardware “ain’t cheap,” he notes.

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