RSSAll Entries in the "Life Safety Code" Category

I said you’ll pay for this mischief…

In this world, or the next! Stand by for news…

In this most momentous of years / survey cycles, it appears that there may be at least one more shift in the firmament, that being a transition for a most notable AHJ. The grapevine has been singing this week. (You can reference either the Marvin Gaye or Gladys Knight version; at the moment, I’m leaning toward an invocation of Marvin as it pushes a follow of “What’s Going On”—Brother, Brother, indeed!) There seems to be a changing of the guard afoot in Mordor (or Oak Park, Illinois—take your pick) as it appears that the estimable Director of Engineering for The Joint Commission, George Mills, is transitioning out of the crucible that provides so much in the way of heartburn in the industry.

Word is that one of the engineers in the Standards Interpretation Group (SIG), John Maurer, will be taking the director’s position on an interim basis. Not by any means a comparison (my personal dealings with the departing incumbent have always been reasonable and assistive), but my past interactions with Mr. Maurer have always been thoughtful, helpful and equitable, including indication of how one might plot a course toward satisfactory compliance. In that regard, I don’t anticipate that this will engender a significant change in how business will be conducted, including the practical administration of the Life Safety portion of the accreditation survey process. While details have not yet been officially confirmed, I have no reason to think that the information in general is incorrect, so all I can say is best of luck to everyone as they (and we) embark on their new journeys and pray for a resurgence of benevolence across the board.

To round things out for this week, I would bring your attention to last week’s Joint Commission Quick Safety Issue (QSI #35 in an ongoing series—collect ‘em like baseball cards!) and the topic du jour: minimizing noise and distractions in OR and procedural units.

Now, you’ll get no argument from me that there are certain environments and situations for which noise minimization is desirable, and perhaps, essential. And, empirically, I can’t disagree with any of the characterizations indicated in QSI #35—there are quite a number of footnotes, none of which I have had the time to track down, but, again, I have no reason to think that the scholarship of the article is anything less than spot on. I guess the thought/question/concern I have relates to the practical application of this as an improvement activity (keeping in full mind that sometimes surgeons like to operate to music that ain’t exactly in the realm of quiet—think AC/DC’s “Back in Black” and you’ll be on the right track).

QSI #35 has a whole list of “safety actions to consider,” and the indication is that these are actions that “should” be considered. (But how often have you seen a “should” become very musty during survey…) I wonder if you’ll have the leeway to make the determination of whether you are appropriately managing noise in the procedural environment. I suppose it’s good that this hasn’t shown up in Perspectives

Reefing a sail at the edge of the world…

What to do, what to do, what to do…

A couple of CMS-related items for your consideration this week, both of which appear to be rather user-friendly toward accredited organizations. (Why do I have this nagging feeling that this is going to result in some sort of ugly backlash for hospitals?)

Back in May, we discussed the plans CMS had for requiring accreditation organizations (AOs) to make survey results public, and it appears that, upon what I can only imagine was intense review and consideration, the CMS-ers have elected to pull back from that strategy. The decision, according to news sources, is based on the sum and substance of a portion of Section 1865 of the Social Security Act, which states:

(b) The Secretary may not disclose any accreditation survey (other than a survey with respect to a home health agency) made and released to the Secretary by the American Osteopathic Association or any other national accreditation body, of an entity accredited by such body, except that the Secretary may disclose such a survey and information related to such a survey to the extent such survey and information relate to an enforcement action taken by the Secretary.

So, that pretty much brings that whole thing to a screeching halt—nice work of whoever tracked that one down. Every once in a while, law and statute work in favor of the little folk. So, we Lilliputians salute whomever tracked that one down—woohoo!

In other CMS news, the Feds issued a clarification relative to the annual inspection of smoke barrier doors (turns out the LSC does not specifically require this for smoke doors in healthcare occupancies) as well as delaying the drop-dead date for initial compliance with the requirements relating to the annual inspection of fire doors. January 1, 2018 is the new date. If you haven’t gotten around to completing the fire door inspection, I would heartily recommend you do so as soon as you can—more on that in a moment. So, good news on two fed fronts—it’s almost like Christmas in August! But I do have a couple of caveats…

I am aware of 2017 surveys since July in which findings were issued because the inspection process had not been completed, and, based on past knowledge, etc., it is unlikely that those findings would be “removable” based on the extended initial compliance date. (CMS strongly indicates that once a survey finding is issued in a report, the finding should stay, even if there was compliance at the time of survey.) So hopefully this will not cause too much heartburn for folks.

The other piece of this is performance element #2 under the first standard in the Life Safety chapter. (This performance element is not based on anything specifically required by the LSC or the Conditions of Participation—yet another instance of our Chicagoan friends increasing the degree of difficulty for ensuring compliance without having a whole mess of statutory support, but I digress.) The requirement therein is for organizations to perform a building assessment to determine compliance with the Life Safety chapter—and this is very, very important—in time frames defined by the hospital. I will freely admit that this one didn’t really jump out at me until recently, and my best advice is to get going with defining the time frame for doing those building assessments; it kind of “smells” like a combination of a Building Maintenance Program (BMP) and Focused Standards Assessment (FSA), so this might not be that big a deal, though I think I would encourage you to make very sure that you clearly indicate the completion of this process, even if you are using the FSA process as the framework for doing so. In fact, that might be one way to go about it—the building assessment to determine compliance with the Life Safety chapter will be completed as a function of the annual FSA process. I can’t imagine that TJC would “buy” anything less than a triennial frequency, but the performance element does not specify, so maybe, just maybe…

Civilization and its discontents

A bit of a hodge-podge this week, with the thematic element of security being the tie that binds, so to speak. There continues to be a lot of news (or it certainly seems that way to me) lately about various security concerns, from violence in the workplace to incursions by unauthorized persons into restricted and/or sensitive areas. We have spent a fair amount of time on these subjects this year (and I somehow suspect that this won’t be the last time for discussion in this realm), but I did want to share some resources with you in case you missed them in the deluge of this, that, and the other thing. (I sometimes marvel that I manage to capture anything, given the fire hose of information constantly spewing into the ether, but I digress.) So, in (relative) brief:

Hospitals & Health Networks (H&HN) published a very interesting story last week about efforts by Milwaukee-based Aurora Health Care to use a clinical approach to reducing assaults in their workplace, including establishment of a Behavioral Emergency Response Team (BERT)—I think you’re going to become very familiar with this term. At any rate, a lot of valuable information, so if you’ve not yet checked it out, I would encourage you to do so (“Violence in the Hospital: Preventing Assaults Using a Clinical Approach“).

In the comment section at the end of the H&HN article, an individual left a comment regarding a public health film titled “One Punch Homicide” that might be of benefit as a preventive measure. I have yet to watch the documentary in its entirety—the trailer is pretty intense—then again, there’s nothing not brutal about violence. The film runs about 90 minutes, but, as information, if nothing else, it’s worth a look:

As our final thought for this week’s adventure, our friends in Chicago are covering the dangers of tailgating. (I guess since the featured videos are Massachusetts-sourced, the concept of tailgating takes on a whole ‘nutha dimension.) As you will recall, a few months earlier, there was an incident involving an interloper at a hospital in Boston. Since then, the security folks have been hard at work coming up with inventive ways to get folks to use those eyes in the back of their head.

Since it is impossible to determine how much influence anything from Chicago might have on the survey front, I would encourage you (I’m very encouraging this week, aren’t I?) to check out the blog by Dave Corbin, director of security and parking at Brigham and Women’s Hospital in Boston, and maybe show these videos to your EOC Committee and maybe others in your organization—this is one of those things that is scary because it’s true (“Leading Hospital Improvement: New Campaign Illustrates Need for Staff Training on Dangers of Tailgating”).

Hope the summer is treating you well—keep it cool and keep it tuned to

We hold these truths…

In the wake of the high-rise fire in London a few weeks ago, those of you with high-rise facilities are probably going to experience some intensified attentions from your local fire folks (it’s already started in Houston). Any time there is a catastrophic fire with loss of life, it tends to result in an escalation in the interests of the various AHJ’s overseeing fire safety. While I suspect that your facilities are not at risk to the extent the conditions at the Grenfell Tower appear to have been, it is very likely that your locals are going to want to come out and kick the tires a little more swiftly/demonstrably than they have in the past. And, since we are responsible for a fair number of folks who are not (or at least less than) capable of getting themselves out in a fire, I think there is a very strong possibility that scrutiny will extend to non-high-rise facilities as well. I think we can say for pretty much certain that the regulatory folks probably didn’t miss this as a news story, and it’s not a very big leap to want to apply any lessons learned to how their areas of responsibility would fare under intensified scrutiny.

As a related aside, one of the challenges that I periodically face in my consulting engagements is the pushback of “it’s always been like this and we’ve never been cited” or something similar. My experience has been that a lot of times, the difference between a good survey and a not-so-good survey can be the surveyor taking a left turn instead of a right, etc. We have certainly covered the subject of imperfect buildings and how to find them (they are, after all, everywhere you look), so I won’t belabor the point, but this probably means that the focus on the physical environment is going to continue apace, if not (and I shudder at the thought) more so. We’ve got a lot of work ahead of us, folks—let’s get those sleeves rolled up!

Finally, as a head’s up, there’s going to be a webinar in August hosted by HC Info on strategies for meeting the CMS guidance (almost makes it sound helpful, doesn’t it) relative to the management of legionella risk that we covered a few weeks back. (Apparently space is limited, so you might want to get right on this:

Something (nothing official, just an intense feeling) tells me that this is likely going to be a significant survey focus over the next little while, so I’m in favor of gathering as much expert information, etc. as possible. Again, while I have no reason to think that most folks are not appropriately managing these types of risks, I also know that the survey expectation bar appears to have been raised to an almost impossible-to-attain level. To echo the motto of the Boy Scouts—Be Prepared!

If brevity is the soul of wit…

Hope everyone enjoyed a festive and (most importantly) safe Independence Day—with any luck, today (July 5) does not mark the end of summer (as some do say) so much as it marks the beginning of the end of spring (up here in the Northeast, spring was loath to depart, but it does seem that pre-autumn weather has finally made a commitment to spending some time in the northern hemisphere).

I was looking recently at past blog posts for a reference to the CMS stance on law enforcement interactions with patients as a function of restraints and patient rights—always a fun topic—and I noted that the posts used to be a mite briefer than tends to be the case of late. (You can be the judge of whether my decline in brevity has left me soulless or witless.) I absolutely recognize that there’s been a lot of stuff to cover over the past 18 months with the firestorms of compliance that swept the healthcare environment, which has (no doubt) promoted some of the “volume” of bloggery. But it has caused me to wonder whether I am consuming the compliance elephant in sufficiently small bites to be of use to you folks out there in the field. As near as I can tell, the purpose of this whole thing (as much as I enjoy having a place to pontificate) is to provide information and thoughts on what is happening at the moment to you, my faithful audience of safety folk. And (as near as I can tell) it never hurts to ask one’s audience whether this works for you—please feel free to give me an e-dope slap if you think the “Space” has gone intergalactic in a less-than-useful way. At any rate, I am going to experiment with smaller bites of information in the coming weeks so you’ll have more time for other things—perhaps outdoors…

As far as news goes, things are relatively quiet as we observe the anniversary of CMS’s adoption of the 2012 Life Safety Code. Hopefully you all have done your NFPA 99 risk assessments; polished off those door inspections and are speeding towards the completion of activities relating to initial compliance with the Emergency Preparedness Final Rule. Health Facilities Management This Week discussed some prepublication EC/LS standards relating to the testing of emergency lighting systems; inspection and testing of piped medical gas and vacuum systems; and updating pertinent NFPA code numbers. The pre-pub stuff is aimed at behavioral health care, laboratory, nursing care center, and office based surgery accreditation programs. You can find the details here:

(I guess some of those links are about as brief as I am…)

Thanks, as always, for tuning in—I really appreciate having you all out there at the other end of the interweb…see you next week!

Point the finger (doesn’t matter which)

Or extend your hand?

First up, as a general rule of thumb (which could be one of the pointed fingers represented above, unless you don’t think a thumb is a finger), when CMS identifies an implementation date that is in the future, I think that we can safely work towards being in full compliance with whatever the Cs are implementing—on that implementation date. Apparently there’s been enough confusion (not really sure who may or may not have been confused, but sometimes it’s like that) for CMS to issue something of a clarification as to what is expected to be in place by November 15, 2017, which means education and exercises (and any other pesky items in your EM program that didn’t quite synch up with the final rule on emergency preparedness for healthcare organizations). Since this is very much brave new world territory when it comes to how (though perhaps the correct term would be “how painfully”) CMS is going to administer the final rule as a function of the survey process. I think it initially, unless we hear something very specific otherwise, means that we need to be prepared to meet the full intent of the language (making sure that you have trained/educated “all” staff; making sure that you participated in a community-wide exercise of some level of complexity) until these things start to sort out. My gut tells me that if they were going to engage in any more exculpatory/explanatory/clarifying communications, it would have been included in the above-noted transmission. And while I have little doubt that there will be some variability (states do not necessarily coordinate response) as to how this all pans out in the field, the education of “all” staff and participation in the communitywide exercise deal seem to be pretty inviolable. Certainly there have been instances in the past in which healthcare organizations have struggled to coordinate exercises with the local community(s), but my fear is that if you fall short on this, you will need to have a very compelling case of why you weren’t able to pull off a coordinated exercise. Community finances and fiscal years and local emergency response hegemony are all contributing factors, to be sure, but where you could “sell” that as a reason for not dancing with the locals to some of the accreditation organizations, I’m thinking that (as is usually the case) reasonableness and understanding might not be the highlights of any discussion with the feds and those that survey on their behalf. From what I’ve seen in the field, when it comes to CMS and the survey process, you are either in compliance or you are not in compliance and there is very little gray in between. Community drill done—compliant! Community drill not done—not compliant! Wouldn’t it be nice if life were always that simple?

At any rate, just to use this a reminder that the first anniversary of the 2012 Life Safety Code® is coming up—make sure you get all that annual testing and such out of the way—and don’t forget to make sure that all your fire alarm and suppression system documentation includes the correct version of the applicable NFPA code used for testing. I am dearly hoping to retire EC.02.03.05 from the most frequently cited standards ranks and while I fear the worst with this change. (To my mind, getting tagged for having the wrong NFPA year on the documentation would pretty much suck—please excuse my coarse language—but sucking is exactly what that type of finding would do.)

I understand all destructive urges

It seems so perfect…

A couple of somewhat disparate, but important, items for your consideration this week. I’m still somewhat fixated on how the survey process is going to manifest itself (regardless of which accrediting organization is doing the checking—including the feds). There are one or two clues to be had at the moment and I am most hopeful that the reason there is so little information coming out of the survey trenches is because there have been minimal change of a drastic nature/impact.

So, on to the discussion. As noted above, while the topics of conversation are indeed somewhat disparate, they do share a common theme—perhaps the most common theme of recent years (not to mention the most common theme of this space): the hegemony of the risk assessment. The topics: management of the behavioral health physical environment, and the risk assessment of systems and equipment indicated by NFPA 99-2012 Health Care Facilities Code. Fortunately, there are resources available to assist you in these endeavors—more on those in a moment.

For the management of the behavioral health physical environment, it does appear that our good friends in Chicago are making the most use of their bully pulpit in this regard. Health Facilities Management had an interesting article outlining the focus that would be well worth your time to check out if you have not already done so. I can tell you with absolute certainty that you need to have all your ducks in a row relative to this issue: risks identified, mitigation strategies implemented, staff educated, maybe some data analysis. As near as I can tell, not having had an “event” in this regard is probably not going to be enough to dissuade a surveyor if they think that they’ve found a risk you either missed or they feel is not being properly managed. If I have said this once, I couldn’t tell you how many times I’ve said it (if I had a dollar for every time…): It is, for all intents and purposes, impossible to provide a completely risk-free environment, so there will always be risks to be managed. It is the nature of the places in which we care for patients that there is a never-ending supply of risky things for which we need to have appropriate management strategies. And I guess one risk we need to add to the mix are those pesky surveyors that somehow have gotten it in to their heads that there is such a thing as a risk-free environment. Appropriate care is a proactive/interactive undertaking. We don’t wait for things to happen; we manage things as we go, which is (really) all we can do.

As to the risk assessment of systems and equipment, as we near the first anniversary of the adoption of the 2012 edition of the Life Safety Code® (LSC) (inclusive of the 2012 edition of NFPA 99), the question is starting to be raised during CMS surveys relative to the risk assessment process (and work product) indicated in Chapter 4 Fundamentals (4.2 is the reference point) and speaks of “a defined risk assessment procedure.” I would imagine that there’s going to be some self-determination going on as to how often one would have to revisit the assessment, but it does appear that folks would be well-served by completing the initial go-through before we get too much closer to July. But good news if you’ve been dawdling or otherwise unsure of how best to proceed: our friends at the American Society for Healthcare Engineering have developed a tool to assist in managing the risk assessment process and you can find it here. I think you will find that the initial run-through (as is frequently the case with new stuff) may take a little bit of time to get through. (In your heart of hearts, you know how complex your building is, so think of this as an opportunity to help educate your organization as to how all those moving parts work together to result in a cohesive whole.)


These things have a habit of spreading very quickly in the survey world, so I would encourage you to keep at it if you’ve already started or get going if you haven’t. Even if you don’t have an immediately pending survey, a lot of this stuff is going to be traceable back to your previous survey and with that first anniversary of the LSC adoption rapidly approaching, better to have this done than not.

Do you know the way to TIA?

Last week we touched upon the official adoption of a handful of the Tentative Interim Agreements (TIA) issued through NFPA as a function of the ongoing evolution of the 2012 edition of the Life Safety Code® (LSC). At this point, it is really difficult to figure out what is going to be important relative to compliance survey activities and what is not, so I think a brief description of each makes (almost too much) sense. So, in no particular order (other than numerical…):

  • TIA #1 basically updates the table that provides the specifications for the Minimum Fire Protection Ratings for Opening Protectives in Fire Resistance-Rated Assemblies and Fire-Rated Glazing Markings (you can find the TIA here). I think it’s worth studying up on the specific elements—and perhaps worth sharing with the folks “managing” your life safety drawings if you’ve contracted with somebody external to the organization. I can tell you from personal experience that architects are sometimes not as familiar with the intricacies of the LSC—particularly the stuff that can cause heartburn during surveys. I think we can reasonably anticipate a little more attention being paid to the opening protectives and the like (what, you thought it couldn’t get any worse?), and I suspect that this is going to be valuable information to have in your pocket.
  • TIA #2 mostly covers cooking facilities that are open to the corridor; there are a lot of interesting elements and I think a lot of you will have every reason to be thankful that this doesn’t apply to staff break rooms and lounges, though it could potentially be a source of angst around the holidays, depending on where folks are preparing food. If you get a literalist surveyor, those pesky slow cookers, portable grills, and other buffet equipment could become a point of contention unless they are in a space off the corridor. You can find the whole chapter and verse here.
  • Finally, TIA #4 (there are other TIAs for the 2012 LSC, but these are the three specific to healthcare) appears to provide a little bit of flexibility relative to special locking arrangements based on protective safety measures for patients as a function of protection throughout the building by an approved, supervised automatic sprinkler system in accordance with Originally, this section of the LSC referenced which doesn’t provide much in the way of consideration for those instances (in Type I and Type II construction) where an AHJ has prohibited sprinklers. In that case, approved alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a building to be classified as non-sprinklered. You can find the details of the TIA here.


I suppose before I move on, I should note that you’re probably going to want to dig out your copy of the 2012 LSC when looking these over.

As a quick wrap-up, last week The Joint Commission issued Sentinel Event Alert #57 regarding the essential role of leadership in developing a safety culture (some initial info can be found here). While I would be the last person to accuse anyone of belaboring the obvious (being a virtual Rhodes Scholar in that type of endeavor myself), I cannot help but think that this might not be quite as earth-shattering an issuance as might be supposed by the folks in Chicago. At the very least, I guess this represents at least one more opportunity to drag organizational leadership into the safety fray. So, my question for you today (and I suspect I will have more to say on this subject over the next little while—especially as we start to see this issue monitored/validated during survey) is what steps has your organization taken to reduce intimidation and punitive aspects of the culture. I’m reasonably certain that everyone is working on this to one degree or another, but I am curious as to what type of stuff is being experienced in the field. Again, more to come, I’m sure…

In season, out of season: What’s the difference?

…when you don’t know the reason…

Some Joint Commission goodness for your regulatory pleasure!

For those of you in the audience that make use of the online version of the Accreditation Manual, I would implore you to make sure that when you are reviewing standards and performance elements that you are using the most current versions of the requirements. I think we can anticipate that things are going to be coming fast and furious over the next few months as the engineering folks at TJC start to turn the great ship around so it is in accordance with the requirements of the 2012 edition of just about everything, as well as reflecting the CMS Conditions of Participation. To highlight that change, one example is the requirement for the testing of the fire alarm equipment for notifying off-site fire responders (decorum prevents me from identifying the specific standard and performance element, but I can think of at least things that might serve as placeholders, but I digress); the January 1, 2017 version of the standards indicates that this is to occur at a quarterly frequency (which is what we’ve been living with for quite some time), but the January 9, 2017 version indicates that this is to occur on an annual basis, based on the 2010 edition of NFPA 72. In looking at the 2010 edition of NFPA 72, it would appear that annual testing is the target, but I think this speaks to the amount of shifting that’s going to be occurring and the potential (I don’t know that I would go so far as to call it a likelihood, but it’s getting there) for some miscommunications along the way. At any rate, if you use the online tool (I do—it is very useful), make sure that you use the most current version. Of course, it might be helpful to move the older versions to some sort of archived format, but that’s probably not going to happen any time soon.

Speaking of updates, last week also revealed additional standards changes that will be taking effect July 1, 2017 (get the detailed skinny here). Among the anticipated changes are the official invocation of NFPA 99 as guidance for the management of risk; some tweaking of the language regarding Alternative Equipment Management (AEM) program elements, including the abolition (?!?) of the 90% target for PM completion and replacing it with the very much stricter 100% completion rate (make sure you clearly define those completion parameters!); expansion of the ILSM policy requirements to include the management of Life Safety Code® deficiencies that are not immediately corrected during survey (you really have to look at the survey process as a FIFI—Find It, Fix It!—exercise); the (more or less) official adoption of Tentative Interim Agreements (TIA) 1, 2, and 4 (more on those over the next couple of weeks) as a function of managing fire barriers, smoke barriers, and egress for healthcare occupancies; and, the next (and perhaps final) nail in the coffin of being able to sedate patients in business occupancies (also to be covered as we move into the spring accreditation season). I trust that some of this will be illuminated in the upcoming issues of Perspectives, but I think we can safely say that the winds of change will not be subsiding any time soon.

Also on the TJC front, as we move into the 2017 survey year, those of you that will likely be facing survey, I encourage you to tune in to a webinar being presented on the SAFER (Survey Analysis For Evaluating Risk) matrix, which (aside from being transformative—a rather tall order and somewhat scary to consider) will be the cornerstone of your survey reports. We’ve covered some of the salient points here in the past (this is quickly becoming almost very nearly as popular a topic for me as eyewashes and general ranting), but I really cannot encourage you enough to give this topic a great deal of attention over the coming months. As with all new things TJC, there will be a shakedown cruise, with much variability of result (or this is my suspicion based on past experiences)—it is unlikely that this much change at one time is going to enhance consistency or it’s hard to imagine how it would/could (should is another matter entirely). At any rate, the next webinar is scheduled for Tuesday, March 7, 2017; details here.

Please remember to keep those cards and letters coming. It’s always nice to hear from folks. (It almost makes me think that there’s somebody out there at the other end of all those electrons…) Have a safe and productive week as we await the arrival of Spring!


Doo doo doo, lookin’ out my back (fire) door…

Something old and something new(ish): old rant, new requirement.

As we move ever onwards toward the close of our first year “under” the 2012 Life Safety Code® (talk about a brave new world), there was one item of deadline that I wanted to touch upon before it got too, too much further into the year. And that, my friends, is the requirement for an annual inspection of fire and smoke door assemblies—for those of you keeping track, this activity falls under the EOC chapter under the standard with all those other pesky life safety-related inspection, testing, and maintenance activities (don’t forget to make sure that your WRITTEN documentation of the door assembly inspection includes the appropriate NFPA standards reference—in this case, you have quite a few to track: NFPA 101-2012 for the general requirements; NFPA 80-2010 for the fire door assemblies; and, NFPA 105-2010 for the smoke door assemblies). Also, please, please, please make sure that the individual(s) conducting these activities can “demonstrate knowledge and understanding of the operating components of the door being tested” (if this sounds like it might be a competency that might need to be included in a position description and performance evaluation, I think you just might be barking up the correct tree). The testing is supposed to begin with a pre-test visual inspection, with the testing to include both sides of the opening. Also, if you are thinking that this is yet another task that will be well-served by having an inventory, by location, of the door assemblies, you would indeed be correct (to the best of my knowledge). As a caveat for this one, please also keep in mind that this would include shaft access doors, linen and trash chute—while not exactly endless, the list can be pretty extensive. At the moment, from all I can gather, fire-rated access panels are optional for inclusion, though I don’t know that I wouldn’t be inclined to have a risk assessment in one’s back pocket outlining the decision to include or not to include (that is the question!?!) the access panels in the program.

I’m thinking you will probably want to capture this as a recurring activity in your work order system, as well as developing a documentation form. Make sure the following items are covered in the inspection/testing activity:


  • No open holes or breaks in the surfaces of either the door or the frame
  • Door clearances are in compliance (no more than ¾ inch for fire doors; no more than 1 inch for corridor doors; no more than ¾ inch for smoke barrier doors in new buildings)
  • No unapproved protective plates greater than 16 inches from the bottom of the door
  • Making sure the latching hardware works properly
  • If the door has a coordinator, making sure that the inactive door leaf closes before the active leaf
  • Making sure meeting edge protection, gasketing, and edge seals (if they are required—depends on the door) are inspected to make sure they are in place and intact


I think the other piece of the equation here is that you need to keep in mind that “annual” is a minimum frequency for this activity; ultimately, the purpose of this whole exercise is to develop performance data that will allow you to determine the inspection frequency that makes the most sense for compliance and overall life safety. Some doors (and I suspect that you could rattle off a pretty good list of them without even thinking about it too much) are going to need a little more attention because they “catch” more than their fair share of abuse (crash, bang boom!). Now that this isn’t an optional activity (ah, those days of the BMP…), you might as well make the most of it.


Putting on my rant-cap, I’d like to steal just a few moments to lament the continuing decline of decency (it used to be common; now, not so much) when it comes to interactions with strangers (and who knows, maybe it’s extending into familial and friendial interactions as well—I sure hope not!) I firmly believe that any and every kindness should be acknowledged, even if it’s something that they were supposed to do! My favorite example is stopping for pedestrians (and if you’ve been behind me, yes that was me stopping to let someone complete the walk); yes, I know that in many, if not most, places, the law requires you to stop for pedestrians in a crosswalk, but I think the law should also require acknowledgement from the pedestrians. Positive reinforcement can’t possibly hurt in these types of encounters. Allowing merging traffic to move forward (signaling is a desirable approach to this, but you should also signal the person who let you in). I’m not sure if we’re just out of practice or what, but I’d ask you to just try a little more to say “hi” or “thanks” or give somebody a wave when they aren’t jerks (and just so we’re straight, a wave includes more than just the middle digit). Maybe I’m going a little Pollyanna here, but the world is just not nice enough lately. Hopefully we can make an incremental improvement…