By Dan Arce
AHCA, CMS and the State Fire Code all require annual fire door inspections because it only takes one defective or non-compliant fire door to enable a small fire to turn into a deadly inferno.
The purpose of these agencies is to increase public safety by ensuring Medicare-funded healthcare facilities are complying with all fire and life safety codes and concerns.
Next to sprinkler systems, Code Compliant, Fire, Smoke and Egress doors are a facility’s most crucial fire prevention device. Most fires usually start small and can be limited to the original area – providing that any fire door leading from the room is fire-code compliant. In addition, it is a fact that very few people are hurt or die from flames; it’s smoke and fumes that injure and cause death. Therefore, fire doors blocking the spread of fire, smoke, etc., are essential. In addition, a fire door can cut off additional oxygen from entering the fire zone and fueling the blaze, proving it is fully compliant with the fire code.
“Fire Safety” doors have the most potential for failure due to the high frequency of use and sometimes simply the lack of regular maintenance. Because of this reason, a need for strict regulatory compliance has been established by (a) National Fire Protection Association (NFPA), (b) International Code Council (ICC), and (c) Joint Commission, AHCA, and CMS [Healthcare], fire codes which all require the inspection of fire doors at least annually.
A complete fire door inspection requires several things. First – you need a completed door schedule listing every fire, smoke, and egress door. Each door must be listed individually and its exact location and other information must be noted. (National FireDoor (NFD) attaches a QR-coded permanent ID label to each door’s hinge edge.) Facilities’ floor plans are usually beneficial (some use the Fire “Life Safety Plan’s” for the building).
When AHCA or other AHJ (Authorities Having Jurisdiction) shows up to do a life safety survey, one of the records facilities must keep available is a Fire Door-ITM workbook or report. (ITM stands for – Inspection, Testing and Maintenance.) This report is a permanent record of the ITM for each door and must be available upon demand.
An annual inspection of ALL fire, smoke and egress doors is require and a report for EACH door must be made available to AHJ upon request. In addition, your facility can be cited for failing to comply with the Annual Fire Door Inspection (AFDI) Mandate requirements. Never forget, it’s facilities management who is held responsible for required safety inspections.
You may ask who is authorized to do the AFDI. The NFPA code states that anyone who possesses the proven knowledge of Fire Safety Door Assemblies and Fire Code compliance experience is eligible as an inspector, providing that they are acceptable to the AHJ. Most facilities utilize the services of professional companies such as National FireDoor, LLC (NFD), one of the fastest-growing companies in the Fire Door inspection field.
National FireDoor offers several programs that run from full service (including everything necessary for compliance with the directives required for Annual Fire Door Inspections) to supervision of an in-house program.
NFD can ensure your buildings conform to the inspection requirements for your facility. For a no-obligation consultation, contact NFD at (305) 233-1477 or info@Nationalfiredoor.com. We can make your buildings compliant now and in the future.
