DH Pace Helps Hospital Meet Door Code Requirements

Category: Inspection and Maintenance
Products: FireCheck® Program
Industry: Health Care
Application: Inspection Services and Code Compliance


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. In it, they 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, 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

Based on the results of the FireCheck® Program inspection, the medical center acted on DH Pace’s recommendations. They contracted with DH Pace to provide and install all the materials necessary to bring the facility to 100% compliance.

DH Pace provided the following products:

  • Approximately 8,000 feet of smoke seal
  • 85 Door kick plates in various sizes
  • Approximately 80 mortise door edges
  • 25 Continuous hinges
  • 100 Brush sweeps
  • 20 Fire bolt door hardware
  • 20 New closers

The team fully replaced ten openings and relabeled approximately 150 openings to be labeled in accordance with compliance.

In addition to the summary and written report, the FireCheck® Program includes an annual re-inspection for the following year to ensure continued code compliance.


All told, DH Pace updated nearly 500 openings across the medical center to be code complaint. With just a few weeks before the project was to be completed, representatives from The Joint Commission arrived to inspect the facility.

The inspection went so well, the medical facility stated that the inspection representatives said they had set the standard for any health care facility and that theirs was one of the best inspections they had ever done.