Deficiency in Hazardous Area Enclosure
Penalty
Summary
The report identifies a deficiency in the protection of hazardous areas within the facility. Specifically, hazardous areas such as boiler and fuel-fired heater rooms, laundries larger than 100 square feet, repair, maintenance, and paint shops, soiled linen rooms exceeding 64 gallons, trash collection rooms exceeding 64 gallons, combustible storage rooms or spaces over 50 square feet, and laboratories classified as severe hazard are not adequately enclosed. These areas are required to be protected by a fire barrier with a 1-hour fire resistance rating or an automatic fire extinguishing system. However, the report indicates that the separation of these areas is not achieved as there is no automatic sprinkler system in place, and the necessary smoke-resisting partitions and doors are not installed as per the standards outlined in sections 8.4 and 19.3.5.9. This lack of compliance with fire safety regulations poses a significant risk to the safety of the facility's occupants.
Plan Of Correction
1. Soiled utility room door will be adjusted for smoke-tight gap. 2. Soiled utility room door gaps will be checked for smoke-tight gap. 3. Maintenance will be re-educated on ensuring that all doors are smoke-tight. 4. Maintenance Director/designee will conduct random audits to verify that doors are smoke-tight weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at QAPI meeting for review and recommendations.