TJC Issues Clarifications to Life Safety Code Requirements

PUBLISHED: May 25, 2017
Relevant to: Ambulatory Care, Hospitals, Long Term Care, Medical Office

The Joint Commission (TJC) has issued clarifications to four of their Life Safety Code requirements. StayAlert! will review each clarification individually. Today’s notice reviews requirements related to annual door inspection.

NFPA 80-2010, Standard for Fire Doors and Other Opening Protectives, and NFPA 105-2010 Standard for Smoke Door Assemblies and Other Opening Protectives, per NFPA 101-2012 section requires annual inspection and testing of fire doors and smoke door assemblies.

TJC addresses this requirement under EC.02.03.05, EP 25

According to TJC, annual inspection and testing must be completed by July 5, 2017, which is one year after the Centers for Medicare and Medicaid Services (CMS) regulatory adoption of NFPA 101-2012.

In their clarification, TJC lists the following types of doors that, based on, require annual inspection:

  • Door leaves equipped with panic hardware or fire exit hardware in accordance with
  • Door assemblies in exit enclosures
  • Electrically controlled egress doors
  • Door assemblies with special locking arrangements subject to

TJC further clarifies that corridor doors, i.e., patient room doors and office doors (so long as the room doesn’t contain flammable or combustible materials) do not need to be included in the annual inspection. However, TJC states that while corridor doors that are not required to be fire doors or smoke door assemblies are not subject to the NFPA annual inspection and testing, they should still be routinely inspected as part of an organization-wide building maintenance program.

Included with today’s notice are example policies related to the above TJC clarifications.

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