Education – Documenting Doors

Documenting Door Inspections

Inspection Documentation

The Joint Commission (TJC) began preparing healthcare facilities for life safety systems inspections when the Statement of Conditions (SOC) compliance document was implemented.

The SOC is intended to be a continually updated, maintained management document. It is designed to aid an organization’s critical self-assessment of its current level of compliance with life safety requirements and describe how it will resolve any Life Safety Code (LSC) deficiencies. It should be utilized to continually identify, assess, and resolve LSC deficiencies.

SOC - Four Parts

The SOC has four parts:

1. Introduction & Instructions – contains information and guidance for completing the SOC.

2. Basic Building Information (BBI) – collects general information about each healthcare facility.

3. Life Safety Assessment (LSA) – assesses an organization’s general compliance with the requirements of NFPA 101® – 2012, the Life Safety Code (LSC).

4. Plan for Improvement (PFI) – formally documents an organization’s plan to resolve identified LSC deficiencies.

Part 2, Basic Building Information

One component of the BBI is the facility Life Safety Drawing. The Life Safety Drawing(s) must reflect actual conditions and must be readily accessible. These drawings must contain the following information to be compliant:

  • ​A legend clearly identifying fire safety features
  • Hazardous area locations
  • Fire-rated barrier locations
  • Smoke barrier/smoke compartment locations
  • Suite boundaries and sizes
  • Door locations
  • Exits, including exit stairs and ramps
  • Horizontal exits / Exit passageways
  • Linen and Waste Chute locations
  • Shaft locations
  • Approved equivalencies If the building is partially sprinkler protected, a means of identifying which portions of the facility are fully sprinkler protected

The following information – including a designation in the legend - is beneficial:

  • Fire alarm pull station locations
  • Fire extinguisher locations
  • Fire damper locations
  • Hourly rating of fire-rated barriers
  • Fire and smoke doors, their swing direction, and hour rating
  • Identify doors having access controls or special locking arrangements, including behavioral locking
  • Intended egress routes and egress travel distance
  • Strategic locations throughout the facility (marked on the ceiling) that may be used as reference points

Documenting Door Inspections

Identifying doors requiring annual inspection is a relatively straight forward process if the Life Safety Drawing(s) is(are) documented as described.

Since door inspections (and reports) are an annual requirement, identifying doors with an alpha-numeric designation makes documenting the inspection, repairs, and reporting much easier and less time consuming. Labeling the doors is also beneficial.

DepartSure’s knowledgeable door inspectors educate your team on this process. We also aid developing a door designation system, as well as completing the labeling process. Contact us to discuss your needs.