DH Pace Helps Hospital Meet Door Code Requirements


A not-for-profit health care network with over 550 beds wanted to meet door code requirements for The Joint Commission also known as (JCAHO) accreditation. National Fire Protection Association (NFPA) standards require building owners to have rolling, sliding, and swinging fire doors inspected and tested annually. NFPA standards also require to maintain written documentation of such inspections.


In a previous year, the health care network performed a fire door certification inspection and found that most of the openings failed to meet NFPA 80 standards.

The following year, the customer wanted to re-inspect the doors. Knowing that doors that did not meet quality standards threatened their accreditation with The Joint Commission. The Joint Commission accreditation and certification is considered a quality symbol that reflects on an organization’s commitment to meet specific performance standards. Failure to maintain accreditation can result in a loss of federal funding and bad publicity which can negatively affect their reputation in the community.


The medical center enrolled in the FireCheck® Program to identify all openings that did not meet the standard requirements. First, DH Pace met with the facility’s representatives to coordinate the inspection details. Then, American Association of Automatic Door Manufacturers (AAADM) certified technicians performed an opening survey with a visual inspection and functional tests. After the survey, DH Pace provided a deficiency summary outlining high-level details of the visual inspection and function tests.

Finally, DH Pace submitted a written inspection report of the facility’s openings with recommendations of how the facility could fulfill their legal obligation to maintain openings in compliance with the pertinent codes and standards. The written inspection report covers multiple code sources including the following list:

• International Building Code (IBC)
• International Fire Code (IFC)
• NFPA 80 for the care and maintenance of fire doors and other opening protectives
• NFPA 101 for life safety
• NFPA 105 for installation, maintenance, and testing of smoke door assemblies and smoke dampers