Understanding how to prevent one of the most frequently cited deficiencies in critical access hospitals is fundamental to maintaining the safety of patients, personnel, and everyone else who passes through a hospital’s doors.

Ensuring the compliance of fire-rated door assemblies helps protect and maintain building occupant safety. Deficiencies with fire-rated door assemblies typically represent 45% of critical access hospital citations.

The Accreditation Commission for Health Care (ACHC) Critical Access Hospital Accreditation Standards Manual addresses the importance of fire-rated door assemblies.

Standard 14.04.07 requires that fire-rated door assemblies meet the provisions of the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Fire Windows, 2010 edition. All fire-rated door assemblies, whether located in a fire-rated barrier or not, must be tested and inspected on an annual basis according to NFPA 80, 2010 edition.

• Door testing components include label legibility, which allows identification of the door’s fire rating.
• Each frame also must have a legible label identifying its fire rating. (Frames are not required to be labeled with an hourly rating, unless the assembly rating is for three or more hours.)
• Fire-rated door assemblies must have self-closing devices, positive-latching hardware, gaps of no more than one-eighth of an inch between meeting edges of door pairs, and a space of no more than three-quarters of an inch between the bottom of the door and the floor.

When a Surveyor Visits

When an ACHC Surveyor conducts a survey, you’ll be asked to provide documentation that all fire-rated door assemblies throughout the facility have been inventoried and listed and that all assemblies have been tested and inspected on an annual basis. This includes fire-rated door assemblies that are not located in a fire-rated barrier.

• During the building tour, the Surveyor will examine the fire door labels to ensure each door is properly rated for the fire barrier designation. If the label is not legible, then the door is not compliant.
• The Surveyor will evaluate the gap between meeting edges of each door pair and the undercut of the door to ensure the space is within acceptable limits.
• Any after-market hardware installed on fire-rated doors (astragals, coordinators, closers, etc.) will be inspected to verify each piece is listed for use on fire-rated door assemblies.
• The Surveyor will review the documentation that demonstrates that each individual fire-rated door assembly has been tested and inspected on an annual basis.

Tips for Compliance

Maintaining compliance with fire door safety standards requires testing and documentation.

• A simple test can be performed each time fire drills are performed in your organization to validate compliance. Failures can be promptly identified and targeted for correction.
• Periodic and consistent documentation of hardware ratings, testing, and inventories will help ensure documentation is up to date and complete for your accreditation survey.
• Annual testing and inspection are essential for ensuring the facility remains in compliance.

Here to Help

To access the most recent ACHC Critical Access Hospital Standards Manual, contact your Account Advisor or email us at [email protected].