Failure to Maintain Hazardous Area Enclosures
Penalty
Summary
The facility failed to maintain hazardous area enclosures, as evidenced by an observation on February 10, 2025, at 10:10 a.m. The doors to the Condensing Room, which is classified as a hazardous area, were found to be unable to close and latch properly. This deficiency affected one of the five smoke compartments in the facility. An interview with the Facility Administrator and Maintenance Director later confirmed that the door in the hazardous area enclosure failed to latch, indicating a lapse in maintaining the required safety standards for hazardous areas.
Plan Of Correction
1. The doors to the condensing room will be repaired/replaced to ensure positive latching and resistance to passage of smoke. 2. The maintenance staff will be in-serviced on positive latching and resistance to passage of smoke. 3. The maintenance staff/designee will audit the facility to ensure doors are positive latching to the frame and are resistant to the passage of smoke and report any concerns to the Quality Assurance Performance Improvement committee. 4. The Safety Committee will review the repairs to ensure all corrections are made.