Failure to Maintain Fire Safety in Hazardous Area
Penalty
Summary
The facility failed to ensure that one of eight fire-rated doors to hazardous areas was properly separated by smoke-resisting partitions, as required by NFPA 101, 2012 Edition. During an observation on December 5, 2024, at approximately 9:20 AM, it was noted that the basement level Activities room door did not close to the frame when tested. The automatic door closure mechanism had been removed, preventing the door from self-closing into its frame. This deficiency was confirmed by the surveyor and facility representatives during the Life Safety Code survey exit on December 9, 2024. Inside the Activities room, the surveyor observed several combustible items, including cardboard boxes and activity crafts, which posed a potential fire hazard. The room was measured to be 91.875 square feet, exceeding the 50 square feet threshold for requiring proper fire separation. The presence of these combustible materials, combined with the lack of a functioning self-closing door, constituted a failure to comply with the necessary fire safety standards, as outlined in the relevant sections of NFPA 101.
Plan Of Correction
12/31/24 Immediate Corrective Action: Inspection of all self-closing doors: A comprehensive inspection of all self-closing doors in hazardous areas (boiler rooms, electrical rooms, storage rooms, etc.) was conducted immediately by our maintenance team. Repairs or replacements: Any self-closing doors that are not functioning properly will be repaired or replaced immediately. This includes ensuring that the doors close automatically without obstruction and maintain the required fire-resistance rating. Basement activity storage door new closure was placed. See photo for reference. Identification of Non-Compliant Doors: We will identify and tag any doors that are not compliant and make necessary repairs, ensuring all doors in hazardous areas meet the required standards for self-closing and fire resistance. Systematic Changes to Prevent Recurrence: Routine Inspections and Testing: An annual inspection and testing program will be implemented for all self-closing fire-rated doors in hazardous areas. The program will include: - Verifying the proper operation of the door-closing mechanism. - Ensuring that doors are not obstructed and can close fully. - Checking that fire-rated doors are not damaged. The results of each inspection will be documented and kept on file for review. Long-Term Sustainability: Documentation and Tracking: A detailed log of all self-closing doors will be created, listing the location of each door, its inspection dates, and any repair or maintenance actions taken. Monitoring and Follow-Up: Ongoing Compliance: The facility will schedule annual internal inspections of self-closing doors in hazardous areas to ensure continued compliance. Reports will be reviewed by the facility's fire safety officer and any identified issues will be addressed promptly. The results of the findings will be addressed at the first quarter safety committee meeting and the first quarter QA meeting. Responsible Party: Maintenance Director: Oversees the inspection, repair, and ongoing monitoring of self-closing doors.