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Wednesday 7:26 CST, December 11, 2019



Accreditation and Certification

January 01, 0001

Four clarifications issued for Life Safety Code requirements for EDs, doors and fire drills

LSCNew clarifications have been issued to help organizations with four Life Safety Code© requirements. The guidance is in reference to:

Emergency Department (ED) occupancy classification — Life Safety (LS) LS.02.01.10, Element of Performance (EP) EP 1, LS.03.01.10, EP 1: EDs could be classified as health care occupancies or ambulatory health care occupancies.

  • Facilities that provide sleeping accommodations for persons who are mostly incapable of self-preservation, or that provide housing on a 24-hour basis for occupants, are classified as health care occupancies, per National Fire Protection Association (NFPA) 101-2012, 18/ and 18/
  • An ambulatory health care occupancy is used to provide services or treatment simultaneously to four or more patients that provides, on an outpatient basis, one or more of the following: 
    • Treatment for patients that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others
    • Anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others
    • Emergency or urgent care for patients who, due to the nature of their injury or illness, are incapable of taking action for self-preservation under emergency conditions without the assistance of others. 

(See NFPA 101-2012,

Annual door inspection — Environment of Care (EC) EC.02.03.05, EP 25: Annual inspection and testing is required for fire doors and smoke door assemblies, per NFPA 80-2010, Standard for Fire Doors and Other Opening Protectives, and NFPA 105-2010, Standard for Smoke Door Assemblies and Other Opening Protectives, per NFPA 101-2012 section Annual inspection and testing must be completed by July 5, 2017, which is one year after the Centers for Medicare and Medicaid Services (CMS) regulatory adoption of NFPA 101-2012. Although health care and ambulatory chapters of NFPA 101-2012 do not specifically cite, chapters 18/ refer to 7.2.1. Also, both CMS and The Joint Commission believe these door inspections are beneficial to the ongoing reliability of the organization fire protection program.  

Corridor doors that are not required to be fire doors or smoke door assemblies (e.g., patient room doors) are not subject to the NFPA annual inspection and testing, but should be routinely inspected as part of a facility maintenance program.  

  • Doors to be included in the annual door inspection (based on include: 
    • Door leaves equipped with panic hardware or fire exit hardware in accordance with 
    • Door assemblies in exit enclosures 
    • Electrically controlled egress doors 
    • Door assemblies with special locking arrangements subject to 
  • The Joint Commission does not require the following doors to be included in the annual door inspection:
    • Corridor doors (i.e., patient room doors)
    • Office doors (provided the room does not contain flammable or combustible materials) 

Rated fire door assembly installed in lesser rated or non-rated barrier — LS.01.01.01, EP 6,  EC.02.03.05, EP 25: If the organization has doors that are of “superior quality, strength, fire resistance” (see NFPA 101-2012 1.4), they would be allowed in the assembly.

Existing fire protection features obvious to the public, if not required by the Code, shall be either maintained or removed, per NFPA 101-2012, section Therefore, doors shall be maintained per the barrier assembly requirements, but in cases where a fire-rated door is used in a nonrated barrier assembly, the fire door must be maintained as a fire door unless the features which identify it as a fire door have been removed in a manner that maintains the opening protective requirements applicable to the barrier into which it is installed.

For example, if a 90-mintue, fire-rated door was installed in an existing smoke barrier, the door would need to be annually inspected and tested as a fire door, and the smoke barrier maintained as a smoke barrier. If the 90-minute door was modified to remove all fire door hardware and labeling (i.e., removing the bottom rod and floor receiver) and repaired as a smoke barrier door (see NFPA 105-2010, 5.1.4), the door could be annually inspected and tested as a smoke door.

Fire Drills and Varying Times — EC.02.03.03, EP 3: Fire drills conducted no closer than one hour apart would be acceptable, however, as drills must be performed under varying conditions per 18/ there should not be a pattern of drills being conducted one hour apart.

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