NFPA 101 Compliance in Healthcare Facilities

Feb. 1, 2017
Code changes give health care facilities vital new tools that will help protect patients. However, many of these new applications have extremely complex requirements that must be strictly followed.

Since 2003, the Centers for Medicare and Medicaid Services (CMS) have been using the 2000 edition of NFPA 101 - The Life Safety Code to evaluate the life safety of health care facilities in the United States. But in May of 2016, the CMS published a final rule in the Federal Register, adopting the 2012 edition of NFPA 101, which went into effect on July 5th, 2016.

Many more important changes have been made to NFPA 101 between the 2000 and 2012 editions that locksmiths should be aware of, but this article will be focusing solely on a few of the door-related changes between the two editions.

Fire Door Inspections

Because annual fire door inspection requirements were not included in the 2000 edition of NFPA 101, the mandate for annual inspections is one of the biggest impacts of adopting the 2012 edition of NFPA 101. The 2012 code references the 2010 edition of NFPA 80, which requires fire door assemblies to be inspected annually, and includes a lengthy list of inspection criteria. Because NFPA 80 mandates that any deficiencies found during these inspections must be repaired “without delay,” many healthcare facilities have already begun the process of having their fire door assemblies inspected annually in order to ensure code compliance.

The following criteria are required by NFPA 80 to be evaluated during a fire door inspection:

  1. Labels are present and legible.
  2. No holes or breaks in door or frame.
  3. Glazing and glass kit / glass beads are intact and securely fastened.
  4. Door, frame, and hardware are in proper working order.
  5. No missing or broken parts.
  6. Door clearances are within allowable limits.
  7. Door closer / spring hinges are operational and door is self-closing.
  8. Coordinator ensures that door leaves close in proper sequence (pairs only).
  9. Door is self-latching in the closed position.
  10. Opening is not equipped with auxiliary hardware items which interfere with operation.
  11. No field modifications have been performed that void the label.
  12. Gasketing and edge seals, where required, are present, continuous, and of the proper type for a fire door.
  13. Signage on door covers less than 5 percent of door face and is not attached with mechanical fasteners.

In addition to fire doors, the 2012 edition of NFPA 101 also requires the inspection of egress doors in certain occupancy types – Assembly, Educational, Day Care, and Residential Board and Care.  If a healthcare campus includes any of these occupancy types, certain egress doors must be inspected annually in addition to fire door inspections.

Fire Exit Hardware

Many will recall the industry’s struggle to defend the use of auxiliary fire pins on fire door assemblies with less-bottom-rod fire exit hardware. These pins are designed to project and align the leaves of a pair of fire doors only when exposed to extreme temperatures during a fire, but it was not initially clear to officials that this only occurs when conditions in the vicinity of the door are no longer tenable for human survival and the door opening has ceased to be a viable path of egress. However, the case has since been made in support of their use and as a result, Paragraph was added in the 2012 edition, and allows the use of fire pins for less bottom rod (LBR) fire exit hardware or other hardware on fire door assemblies.

Controlled Egress Locks

One of the biggest challenges faced by hospitals and healthcare facilities has been effectively and safely preventing the elopement and abduction of their most vulnerable patients. Fortunately, new sections specific to healthcare facilities have been added to Chapters 18 (new) and 19 (existing) – sections and  These sections allow egress doors in certain types of health care units to be locked in the direction of egress using an application that is now commonly called “controlled egress.” This change will give health care facilities the ability to improve the security of areas such as behavioral health, memory care, pediatric and maternity units, and emergency departments.

However, stringent safeguards must be in place to help mitigate the potential threat to life safety that these locks create. Fail-safe electrified locks must be used in order to ensure the loss of power to the lock or activation of the smoke detection system will unlock the door. Staff must carry keys or other credentials to unlock the doors at all times, the locks must be able to be unlocked remotely from within the locked smoke compartment and only one controlled egress lock is permitted on each door. In addition, the building must be protected throughout by an automatic sprinkler system.

Electrically Controlled Egress Door Assemblies

Chapter 7 of the 2012 edition of NFPA 101 also includes section – Electrically Controlled Egress Door Assemblies. This new section is typically applied to doors with electromagnetic locks that are released by door-mounted hardware - for example, panic hardware or a lever handle with a request-to-exit (RX or REX) switch or a bar with an electronic touch sensor (a separate code section addresses mag-locks released by a sensor that is not part of the door-mounted hardware). 

Operation of the door-mounted hardware must directly interrupt power to the lock and unlock the door in the direction of egress.  The lock must also release upon loss of power, but unlike an electromagnetic lock released by a sensor, this section does not require the lock to unlock upon actuation of the fire alarm system.  The 2012 edition of NFPA 101 requires new installations of these systems to be listed in accordance with ANSI/UL 294, Standard for Access Control System Units.


The adoption of the 2012 edition of NFPA 101 will give health care facilities vital new tools that will help protect the patients under their care. However, many of these new applications have extremely complex requirements that must be strictly followed in order to maintain the delicate balance between safety and security. NFPA 101 and NFPA 80 should be closely referenced for detailed information, and any questions or concerns should be addressed by the local Authority Having Jurisdiction (AHJ).

Lori Greene, DAHC/CDC, CCPR, FDAI, FDHI is the Manager of Codes and Resources for Allegion. For more information about this topic and to download a free reference guide on codes, visit

About the Author


Lori Greene, DAHC/CDC, CCPR, FDAI, FDHI, is manager, codes and resources at Allegion. Visit her website,