Life Safety Compliance for Doors in Healthcare

Fire Doors in Healthcare

Having doors perform well in a healthcare setting is a 'must'.

Doors in any healthcare related environment take a beating from equipment commonly found there, including hospital beds, ambulance gurneys, stretchers, wheelchairs, people on crutches, heavy carts, and people in a hurry.

It’s no surprise – hospital doors can be abused.

​With the Centers for Medicare and Medicaid Services (CMS) having formally adopted the 2012 edition of the Life Safety Code, NFPA 101, on May 4, 2016, having doors physically meet requirements, as well as having inspection reports available for review, is crucial to accreditation.

Door Inspections in Healthcare 

The development of door inspection requirements is explained here.

In summary, fire and smoke door inspection requirements were incorporated into NFPA standards, NFPA 80 and NFPA 105, respectively, in 2007.

These standards are referenced by building, fire, and life safety codes such as IBC -2009, IFC -2009, and NFPA 101 -2012, respectively.

These model codes have been adopted by a majority of states and other jurisdictions and are now enforced. (ICC Codes by State).

The Center for Medicare and Medicaid Services (CMS) issued a ‘final rule’ on May 4, 2016 adopting the 2012 edition of the Life Safety Code, NFPA 101 -2012. (Press Release)

CMS, The Joint Commission (TJC), and other accrediting agencies will use NFPA 101 -2012 to assess life safety systems in healthcare facilities as early as July 2016.

Inspections required by The Life Safety Code, NFPA 101 -2012

NFPA 101

The Life Safety Code requires annual inspection of the following doors (

1) Door leaves equipped with panic hardware or fire exit hardware

2) Door assemblies in exit enclosures

3) Electrically controlled egress doors (i.e. power operated doors)

4) Door assemblies with special locking arrangements.

The Life Safety Code also requires inspection of fire-rated door assemblies per NFPA 80 and inspection of smoke door assemblies per NFPA 105. (

Inspections must include visual and functional review (,

In addition to the inspection items defined in NFPA 80 and NFPA 105 for fire and smoke doors, respectively, the following specific items must be verified and documented for all doors (

1) Floor space clear on both sides of door

2) Forces required to open the door meet ADA requirements

3) Latching and locking devices meet requirements

4) Releasing hardware meets requirements

5) Paired door leaves meet requirements

6) Door closers meet closing speed requirements

7) Door leaf projection meets requirements

8) Powered door leaves operate per requirements

9) Signage, where required, meets requirements

10) Door openings with special locking arrangement meet requirements

11) Security devices do not impede egress

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Finally, inspections must be documented, signed, and the documents maintained by a “knowledgeable individual” for inspection by an AHJ ( (What is an AHJ?).

DepartSure's door specialists can complete the necessary inspections and documentation to make life safety compliance easy. Contact us today to learn more.