TJC Clarification about Rated Fire Door Assembly Installed in Lesser Rated or Non-rated Barrier

PUBLISHED: Jun 2, 2017
Source: The Joint Commission
Relevant to: Hospital

The Joint Commission recently issued a series of clarifications related to the Life Safety Code. Today’s Notice reviews clarifications around the use of a fire-rated door in a non-rated assembly.

According to TJC, standards LS.01.01.01, EP 6 and EC.02.03.05, EP 25 address the use of a rated fire door assembly installed in lesser rated or non-rated barrier. TJC states that “…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.”

TJC further clarifies that if there are existing fire protection features obvious to the public that are not required by the Life Safety Code then those features should be maintainer or removed as prescribed by NFPA 101-2012, section 4.6.12.3.

“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.”

Joint Commission gives an example of the above scenario:

  • A 90-mintue, fire-rated door 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.

Follow the link below for additional information. Included with today’s notice are example policies related to this topic.

Want to read the full alert and receive alert emails?

Browse Additional Alerts