Deficient Smoke-Resistant Separation in Hazardous Areas
Penalty
Summary
The facility failed to ensure that hazardous areas were adequately protected with smoke-resistant separation in sprinklered locations, affecting all three levels of the building. During an observation conducted on January 22, 2022, several deficiencies were noted. On the basement level, the Maintenance and Housekeeping Laundry Room door and Boiler Room door #2 were found to be defective as they failed to close and latch properly. This failure in door functionality compromised the smoke-resistant separation required for these hazardous areas. Additionally, on the second floor, soiled linen carts filled with linen were improperly stored in the corridors, which is against the regulations for hazardous area management. On the first floor, the Annex Diaper Room was found to have multiple unsealed penetrations in the entry door, further compromising the smoke-resistant barrier. These observations were confirmed during an exit interview with the Facility Administrator and Maintenance Director, indicating a lack of maintenance in hazardous enclosures.
Plan Of Correction
Maintenance and Housekeeping Basement level laundry room doors have been repaired. Boiler rm #2 door has been repaired. Soiled linen carts have been removed. Annex Diaper Room penetrations have been sealed with an approved through-penetration fire sealant. Maintenance conducted environmental rounds throughout the facility and there were no further hazardous areas. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0321: Hazardous Areas. The interdisciplinary team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported on monthly QAPI.