If you have a door that has a kick plate greater than 16" and was install before the change of code on kickplates , do you have to change out for the UL kickplate. This is existing not new construction
Not sure if this helps any::
Highly suggest email your question to this person:::
If the codes and standards required 16" or less plates when the facility was new, the fire door would have to be maintained with the appropriate height kick plate. Otherwise, it may remain existing. This is where documentation is necessary to substantiate the dates of construction to the LSC surveyors.
Thanks, I was thinking along those same lines. Unfortunately these items was install before I became employed here at the hospital 4 yrs ago
I went through the current CMS Life Safety Code Policy & Memos to States and Regions [Policy & Memos to States and Regions - Centers for Medicare & Medicaid Services] and found no direct interpretations of NFPA 80 for the fire door plates. They appeared not to have issued directives to the LSC survey agents to retrofit fire doors with listed and labeled door plates.
I don't believe, on this basis of the information provided, the fire doors would be required to be retrofitted with labeled door plates. To me it comes down to the scope and severity of the existing fire doors as a distinct hazard to the patients with the existing door plates. For example, a large general storage room directly below sleeping rooms of a hospital requiring 1-hour fire resistant barriers and a 48" high door unlabeled door plate was observed on the fire door inside the storage room. I would be focusing on the scope (number of patients effected) and severity (the extent of the observations) of the problem as a potential harm to the patients if a fire were to occur in the general storage room.
The accrediting organization and/or the state agency contracted by CMS to do the LSC surveys may think differently about the issue. It always a good thing to have non confrontational relationships with both agencies and see how they view the debate.
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