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6/7/2017
1
2012 Life Safety and Health
Care Facility Codes - Door
Inspections and Other Critical
Inspection, Testing and
Maintenance
Will begin at 1 pm
Housekeeping Announcements
• Problems during the call?
Press *0 to be connected to the Operator.
• Handouts
The handouts were attached to the
confirmation email.
If you were unable to access the handouts to
print, please contact the Association at
614/436-4154 after the call and we can
provide those for you.
• Evaluation
Each person listening to the call must complete the evaluation form.
FAX or mail to the Association (FAX: 614-436-0939).
6/7/2017
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Continuing Education Credit
• Wait 24 hours and then Go to http://www.efohca.org and click on ‘Request
Your Certificates’ in the column entitled Live Teleconferences & Webinars.
Certificates are available for 1 year after the program date.
• Find your Facility name in the drop down list. If your facility name is not there,
contact the Association office at 614-436-4154.
• You will enter all participants names at one time. Follow the on screen
instructions.
• You will receive an email when your attendance has been verified and your
certificates are available for download.
• Please note: this course is considered a self study course by Ohio BELTSS.
Administrators are reminded that BELTSS limits teleconference (home/self
study) credits to a total of ten (10.0) per renewal period.
6/7/2017
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Recording
This live program (as well as all previous webinars) are also available via CD
recording. Please note that there are no CEUs available for listening to the
recording. Please contact the Association if you would like to purchase a
recorded copy of a previous webinar.
Also for those listening to the recording, please note the there may have been
changes since the live broadcast of this program. Please contact OHCA or the
speaker for clarification.
Today’s Format
• 90 minutes available for presentation & questions
• Questions?
During the presentation:
you can type your questions
– There will also be time for live questions & answers
at the end of the presentation and the operator will
explain that procedure
6/7/2017
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Today’s Speakers
Kenneth M. Daily - President, Elder Care Systems Group, Dayton, Ohio
Over his 25 plus year career, Kenn has wide-ranging experiences in advancing long-
term health care. Kenn has a strong reputation for designing integrated and
customized solutions for clients to achieve organizational quality and compliance.
Kenn is a member of the Ohio Health Care Association (OHCA) Board of Directors and
Chair of OHCA's Life Safety Code/Disaster Management Committee. He also serves on
the American Health Care Association's Life Safety Committee and the National Fire
Protection Association's Health Care Section where he also serves on its Executive
Committee. Kenn is a recognized author and recently completed editing the NFPA's
2000-2012 Life Safety Code Guidance as well as authoring Life Safety Code Essentials
for Skilled Nursing Facilities' ECSG, 2012.
Critical LSC Inspections – Doors, Sprinklers, Electrical
KENN DAILY, LNHA
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NFPA
Codes adopted effective July 5, 2016
101 Chapter 19 – Existing
101 Chapter 18 -New Facilities
Reference CodesNFPA 10 – Fire Extinguisher – 2010NFPA 13 – Sprinklers – 2010NFPA 25 – Sprinkler Testing – 2010NFPA 70– Electrical – 2009NFPA 72 –Fire Alarm - 2010NFPA 80 – Fire Doors – 2010NFPA 105 – Smoke Doors – 2010 NFPA 220 – Construction - 2010NFPA 96 – Range Hood – 2011NFPA 110 – Generators - 2011
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Doors
NFPA 80Standard for Fire Doors
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces.
(2) Glazing, vision light frames, and glazing beads are intact.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order.
(4) No parts are missing or broken.
(5) Door clearances do not exceed the clearances listed.
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Standard for Fire Doors
5.2.4.2 As a minimum, the following items shall be verified:
(6) The self-closing device is operational
(7) If a coordinator is installed, the inactive leaf closes before active leaf. (pairs only)
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed.
(10) No field modifications to the door have been performed.
(11) Gasketing and edge seals are inspected.
Means of Egress K226
◦Horizontal exits, exit doors or exit access doors cannot be painted/disguised in a manner that obscures their use as a door.18/19.2.2.5.1
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Signs on Fire DoorsThere are two very important conditions regarding signage on fire doors.
1. Signs are for informational purposes only and must not exceed 5% of the area of the face of the fire door that they are attached
2. Signs can only be attached to the fire door with an adhesive. Attaching a sign by using means such as nails or screws are not permitted as they can, and most likely will, void the label on the fire door and affect its performance under fire conditions.
Section 4.1.4 of NFPA 80
Fire-rated Door Clearances
6.3.1.7.1 The clearances between the top and
vertical edges of the door and the frame, and the
meeting edges of doors swinging in pairs, shall be
1/8” + 1/16” for steel doors and shall not exceed in.
1/8” for wood doors.
6.3.1.7.2 Clearances shall be measured from the pull
face of the door(s).
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Clearances Under Doors
Swinging Doors with Builders Hardware
Maximum Clearance of 3/4” Under Door Bottom [4.8.4.1]
Smoke Doors
Maximum clearance of 1” under door bottom - the doors shall be close fitting within operational tolerances
Field Modifications
NFPA 80—Chapter 4
A. Function Holes for Mortise Locks/Latches
B. Holes for Labeled Door Viewers
C. Round Holes for Surface Applied Hardware (up to 1” in Diameter)
D. Through bolts
4.1.3.2, 4.1.3.3 and 4.1.3.4
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Field Modifications That May NOT Permitted
Doors
A. No Vision Panel Cut Outs
B. No Louver Cut Outs
C. No Mortise Lock Pockets
D. No Face or Edge Bores for Bored Locks
E. No Mortise Hinge Preparations
Frames
A. No Mortise Hinge Preparations
B. No Cut Outs
C. Not Holes Cut for other purposes
Fire and Smoke Door Inspections Qualified Training
02/03/17
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Basis of Requirements
NFPA 101 requires annual fire and smoke door inspections (Section 18/19.2.2.2.1) which then requires compliance with Section 7.2.1 which includes 7.2.1.15.2
Section 7.2.1.15.2 requires compliance with:
◦ NFPA 80, Standard for Fire Doors and Other Opening Protectives – 2010 Edition
◦ Section 5.2.1 addresses inspections, testing and maintenance
◦ NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives – 2010 Edition (Section 5.2)
◦ Section 5.2 addresses inspections, testing and maintenance
Door Inspection - NFPA 80
Section 7.2.1.15.2 requires all fire and smoke doors to be inspected and tested, including:
1. Fire rated labeled doors
2. Doors in exit enclosures - typically stairwells and exit passageways
3. Doors in smoke barriers
4. Doors in other fire resistance rated walls such as hazardous areas and fire pump enclosures
6/7/2017
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Doors Testing K 211
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
Inspection and testing requirements for fire-rated door assemblies in accordance with NFPA 80. Inspection and testing requirements for smoke door assemblies in accordance with NFPA 105◦ Applies to new and existing installations
◦ Inspected and tested not less than annually
◦ Written record shall be signed and kept for inspection
◦ Repairs shall be made “without delay”
Who Can?
The inspection is the responsibility of the owner, “performed by individuals with knowledge and understanding”…..so as an owner, does NFPA require me to bring a third-party in to my facility to inspect my fire doors?
Performed by individuals with knowledge and understanding; and that written records are maintained.
NFPA 80 allows for individuals on the facility staff to perform this function if they choose.
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Door Inspection Requirement
This packet has been developed to provide guidance and training to ensure that individuals inspecting and testing door are prepared and qualified.
Door assemblies shall be inspected by a QUALIFIED INDIVIDUAL annually
◦ Reviews operation, door clearance, coordinator, latch and closer
Record kept for AHJ inspection
Fire-rated Door Assemblies NFPA 80
Labels are present and legible No holes or breaks of door or frameNo signs of damage to the door, frame, hinges, and hardwareNo parts are missing or brokenDoor clearances are appropriateSelf-closing device operating properlyIf installed, the coordinator is working Latching hardware operatesNo auxiliary hardware installed that would interfere with operationNo field modifications that would void the labelGasketing and edge seals, if required, are inspected
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Smoke Door Inspection NFPA 105
Smoke door assemblies shall be inspected annually.
◦ Doors shall be operated to confirm full closure.
◦ Hardware and gaskets shall be inspected annually, and any parts found to be damaged or inoperative shall be replaced.
◦ Tin clad and Kalamein doors shall be inspected regularly for dry rot.
◦ A written record shall be maintained and shall be made available to the authority having jurisdiction.
• Fire-rated doors are an integral
part of not just the building’s
passive fire-protection system but
the building’s overall fire
protection.
• A properly operating fire door, just
like a properly operating fire
damper, is a key component in
the compartmentalization of a
building to limit the spread of fire
and restrict the movement of
smoke.
Fire-rated Doors
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• For the fire door to operate successfully, the
entire fire assembly must operate, and the fire
door is just one part of the overall fire
assembly.
• The assembly is composed of the fire door,
frame, fire exit hardware, door closers,
hinges, locks, door bolts, and other door
components that when combined provide
varying degrees of fire protection that is
contingent on the door fire rating (e.g. 45
minutes, 90 minutes). In addition to all of the
components of a fire door assembly, there are
multiple categories of fire doors:
• horizontal sliding;
• fire shutters;
• swinging;
• vertically sliding;
• chutes;
• overhead rolling fire doors.
Understanding the function and parts of door
assemblies
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NFPA 80 Annex
NFPA 80 annex note (addition information which is not enforceable (A.8.3.3.2.3), “steel door frames that are well set in the wall may be judged compliant even when frame label is not legible. The door label, however, must be legible.”
At this point we do not know how SURVEYORs will interpret
Door Parts
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Fire Door Hardware Labeling
In order for a fire door and frame to provide protection against the spread of heat and fire, the hardware used must match the capabilities of the door and frame used. Check for UL listing and ensure hardware is tested for the rating it is matched to. NFPA 101 8.3.3.1
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Fire Exit Hardware
When fire doors are labeled requiring Fire ExitHardware, ensure labels on the hardware match thelabel on the door. NFPA 80, Chapter 6
• Fire doors and door hardware are subject to failure due to their constant usage in high traffic areas, such as busy corridors.
• Constant usage can lead to misalignment of the door, which could potentially lead to failure of the door to close in the event of a fire, which theNFPA claims to be themost common failure of fire doors during an actual fire.
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• Other common non-compliant
issues are holes or openings in
the fire door assembly, improper
gaps, missing labels, failure of
latching hardware to operate,
missing screws, door coordinator
operating improperly, non-
working self-closing devices,
missing gasketing, improper kick
plate (protective plate) sizes,
improper field modifications, and
numerous other problems. All
this must be addressed
When should repair work begin?
• If an inspection shows a deficiency on any fire
protection device including fire doors, repair work
should start without delay.
• You should also report any findings the same day to
your direct supervisor or manager.
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Smoke/Fire Door Inspection
• Door inspection tool was developed for facilities use
• Complete one form for each door inspected.
• It is recommended that a facility identify all doors to be inspected on a drawing/layout of the facility to track inspections.
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Completing Inspection
Facility_______________________________
Tester Name__________________________
Date_________
Door Type: Fire Smoke
Rating _____________________________
Location _____________________________
LocatingFire/ Smoke Doors
Check facility ‘as built’ floor plans.
Tour facility and evaluate each door opening looking for labels.
Remember…
Stairtower and exit doors
Smoke wall doors
Fire Rated labeled doors
Doors to harardous spaces
Door openings. separation between adjoining facilities (NF to ALF) placed at building separations.
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Filling Out Inspection
Operationr Swings freelyr Closes properly r Latches properly r Other _______________
Framer Label present and legible r Is securer No open holes/breaks r Frame not rusted throughr Gaskets intactr Other ________________
Door
r Label present and legible
r Correct Clearance
r No open holes/ breaks
r Glazing/vision light frames intact
r Not Damaged / delaminated door
r Door not rusted-through
r No non-compliant field modification
r No visible signs of damage
r Other __________________
Door Closerr All hardware installed r Strike in good shaper Securely installedr Other __________________
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Filling Out Inspection (cont.)
Hinges r Correct r Securely installedr Other ______________
Flush Bolts r Correct r Securely installed r Other ______________
Lockset / Hardware r All hardware installed r Strike in good shaper Securely installedr Coordinator working properly r Other ______________
Fire Exit Hardwarer All hardware installed r Strike in good shaper Securely installedr Other ______________
Otherr No items that interfere installedr No non-compliant field modificationr Door has appropriate signage r Any signage is properly affixed r Other __________________
Sprinkler Head Inspection Annual)
Inspect all sprinkler heads, including the piping and fittings.
◦ Hanger/ seismic bracing
◦ Pipes and fittings
◦ Sprinkler heads
◦ Documented
◦ Sprinkler heads must be free of foreign materials such as dirt, grime, rust, painters tape, etc.
6/7/2017
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Electrical Equipment Testing K921
Facility must establish policies and protocols for the test intervals and types of tests for all patient care‐related electrical equipment, whether owned or leased.
Documentation must be maintained, with records kept as required by the facility’s record retention policy.
Tests should include:
◦ Date of test
◦ Unique equipment ID number (what was tested)
◦ What was met and not met during the test (result)
10.4, 10.5.2.1
Electrical Equipment Testing K921
Non‐patientcare‐related equipment, whether facility owned or resident owned, must be visually inspected by staff to verify that the device is in proper equipment if it will have contact with residents.
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Testing & InspectionReceptacles – K 914
• Maintenance and Testing
Hospital-grade receptacles at
patient bed locations
• Receptacles not listed as
hospital-grade at these locations
are tested at intervals not
exceeding 12 months.
6.3.4 (NFPA 99)
Testing of Electrical Outlets
NFPA 99 6.3.3.2 lists the following elements:
1. The physical integrity of each receptacle
shall be confirmed by visual inspection
2. The continuity of the grounding circuit in
each electrical receptacle shall be verified
3. Correct polarity of the hot and neutral
connections in each receptacle shall be
confirmed
4. The retention force of the grounding blade
of each receptacle (except locking-type
receptacles) shall not be less than 115g
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LSC compliance
The routine inspection, testing, and maintenance of building systems is an important component of Life Safety Code compliance.
A significant number of deficiencies occur due to the lack of documentation of this inspection, testing, and maintenance.
Survey Documentation
Facility Layout
Features of fire protection -sprinklers and doors
NFPA 99 Risk Assessment
Emergency Battery Lighting◦ Monthly 30 sec. test
◦ Annual 90 min. test
Fire/Smoke Dampers◦ Test and lube every 4yrs.
Fire/ Smoke Door Inspection –Annual
Electrical Equipment – Annual PM
Fire Alarm
◦ Monthly
Fire Alarm Inspection
◦ Quarterly, semi-annual and annual testing
◦ Batteries every 4 yrs.
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Survey Documentation
Fire Drills
Monthly (one/month, per
shift, per quarter)
Fire Pump
◦Weekly, Monthly, Annual
Generator
◦Weekly
◦Monthly
◦ Load Bank (if necessary)
◦ 36 month exercise
Non-Hospital Grade -
Electrical Plug Inspection -
Annual
Hood Suppression
◦ Monthly inspection
◦ Semi-annual
Survey Documentation
Sprinkler System◦ Pressure gauges readings
recorded weekly/dry
◦ Pressure gauges readings monthly/wet
◦ Quarterly and Annual
◦ Annual head inspection
◦ 5yr. internal inspection
Smoke detectors◦ At install, year and every 2
years
Misc. Items
◦ Elevator state certificate/
Annual PM
◦ Boiler certificate
◦ Fire hydrant
◦ HVAC Annual PM
Facility Policies
Fire - Evacuation
Fire Drill - Procedures
Fire Watch
Smoking
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Kenneth Daily, LNHAElder Care Systems Group
Comprehensive consulting for life safety system and disaster management
Consulting and education focusing on quality improvement, survey compliance, and facility management.
Mock surveys and audits
Conduct Fire Safety Evaluation Surveys
Policy and procedure development
Professional development and training