Smoke Barrier Integrity Compromised
Penalty
Summary
The facility failed to maintain the integrity of smoke barrier partitions in accordance with NFPA 101:2012 Edition, Sections 19.3.6.2.3, 8.5.6, 8.5.6.2, and 8.5.6.3. During observations conducted on December 5 and December 9, 2024, in the presence of Facility Management, it was found that three out of twelve smoke barriers had penetrations that compromised their fire resistance rating. Specifically, on the third floor above the ceiling tiles by the 1-1/2 hour fire-rated double corridor doors leading into the "A-Wing," two approximately 1-inch diameter holes with wires running through the smoke barrier wall were observed. Further observations revealed additional deficiencies on the second and first floors. On the second floor, above the ceiling tiles by the 1-1/2 fire-rated double corridor doors leading into the "A-Wing," a 1-1/2 inch diameter hole with nine black wires running through the smoke barrier wall was noted. On the first floor, above the ceiling tiles by the 1-1/2 fire-rated double corridor doors next to the Social Services office, two 1-1/2 inch diameter holes with one BX electrical cable and a 1/2-inch diameter white plastic tubing running through one penetration were found. These deficiencies had the potential to affect all 88 residents in the facility.
Plan Of Correction
Immediate Corrective Action: **Inspection of Fire-Rated Barriers and Doors:** A comprehensive inspection of all fire-rated barriers, including walls and ceilings around fire doors, will be conducted immediately to identify any penetrations that lack proper fire blocking. Areas of focus will include penetrations above fire doors, walls with ducts, pipes, cables, or conduits passing through, and other vulnerable areas in the building. **Sealing Penetrations:** All identified penetrations that lack appropriate fire-blocking will be immediately sealed using approved fire-resistant materials. These materials will include fire-rated caulk, intumescent sealants, or other materials that meet NFPA 101 and NFPA 80 requirements for fire blocking. The materials used will be selected based on NFPA guidelines to ensure that they provide an effective barrier against fire and smoke. **Verification of Fire Blocking:** Once penetrations have been sealed, the Maintenance Director will perform a follow-up inspection to verify that all fire-blocking measures are properly implemented and meet required safety standards. Any issues found during this inspection will be corrected immediately. **Systematic Changes to Prevent Recurrence:** **Contractor Instructions and Oversight:** Moving forward, any contractors who perform work involving penetrations in fire-rated walls, ceilings, or around fire doors will be instructed as follows: Contractors will be required to ensure that all penetrations made during their work are properly fire-blocked in accordance with NFPA 101 and NFPA 80 standards. Contractor contracts will include a clause requiring compliance with all fire safety and building code regulations, including sealing all penetrations with fire-resistant materials. A checklist for contractors will be developed to ensure they have followed fire-blocking protocols before finalizing any work that involves penetrations in fire-rated barriers. **Maintenance Staff Oversight:** Maintenance staff will be tasked with monitoring and inspecting any penetrations made by contractors during construction, repair, or maintenance projects. Maintenance staff will perform follow-up inspections to ensure that any penetrations made by contractors are sealed correctly and fire-blocked immediately. If any deficiencies are found, the Maintenance Director will ensure that the issue is addressed before the area is considered fully operational or before the contractor leaves the job site. **Ongoing Inspections of Fire-Barriers:** The facility's maintenance team will develop a schedule for quarterly inspections of all fire-rated barriers, including doors, walls, and ceilings, to ensure that no unsealed penetrations have been made. Any new penetrations, whether by contractors or facility staff, will be immediately sealed with appropriate fire-blocking materials, and will be included in the inspection schedule for verification. **Fire Safety Training for Staff and Contractors:** Maintenance staff will receive additional training to ensure they are fully knowledgeable about the proper methods for sealing penetrations in fire-rated barriers and identifying potential fire-blocking deficiencies. Contractors will receive orientation or written instructions regarding the facility's fire safety protocols related to penetrations and fire-blocking. This will be reinforced during contractor onboarding before starting any project that involves fire-rated walls. **Follow-Up Monitoring and Compliance:** **Follow-Up Inspections:** A follow-up inspection will be performed within 30 days of completing the immediate corrective actions to verify that all fire-blocking has been implemented properly and that the facility remains in compliance with K372. The inspection will be performed by the Maintenance Director to confirm that all fire-rated barriers are intact and that all penetrations are properly sealed. **Quarterly Audits:** A quarterly fire-safety audit will be conducted to ensure continued compliance. This will include: - A review of all areas where penetrations have occurred. - Verification that all penetrations are properly fire-blocked and meet fire-safety codes. - Auditing the contractor checklist and documentation to ensure that all work completed by contractors adheres to fire safety regulations. **Ongoing Documentation:** Documentation will be maintained for all inspections, corrections, and training sessions. This includes: - Logs of contractor instructions regarding fire-blocking requirements. - Maintenance inspection records and follow-up reports. - Audit results and corrective actions taken. **Responsible Parties:** - **Maintenance Director:** Oversees inspections, repairs, and ensures all penetrations are properly sealed. Also responsible for ensuring maintenance staff follow procedures. - **Contractors:** Responsible for ensuring compliance with fire safety regulations and properly sealing penetrations made during work. **Completion Date for Corrective Action:** All immediate corrective actions, including sealing penetrations and inspecting fire-rated barriers, will be completed by 12/27/24. Ongoing monitoring and quarterly audits will begin immediately and continue per the established schedule. The results will be discussed in the facility's quarterly safety committee meetings.