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K0372
E

Unsealed Penetrations in Smoke Barrier Walls

Philadelphia, Pennsylvania Survey Completed on 01-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain smoke barrier walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on January 21, 2025, at 10:55 a.m., it was noted that in the basement, next to the upper garage elevator, there were penetrations around data wires and a sprinkler pipe. This deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services on the same day at 1:15 p.m.

Plan Of Correction

- ED of construction to Inservice supervisor of Plant Operations on policy and procedure for maintaining smoke barrier walls. - Penetration filled using 3M fire barrier sealant FD 150 + Red color and CP 25 WB+. - Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure. - Audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.

See complete original report
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