Fire/Smoke Barrier Integrity Compromised
Penalty
Summary
The facility failed to maintain the integrity of their fire/smoke barrier construction as required by NFPA 101 standards. During a fire safety tour conducted on February 4, 2025, with the Regional Maintenance Director and the Maintenance Director, it was observed that there were penetrations through both sides of the 1-hour smoke wall in two different hallways. Specifically, at 11:58 AM, a penetration was found above the ceiling of the double fire-rated doors in the 100 Hallway. Similarly, at 12:10 PM, another penetration was identified above the ceiling of the double smoke doors in the 300 Hallway. These penetrations compromise the fire resistance rating of the smoke barriers, which are crucial for restricting the movement of fire and smoke within the facility. The Maintenance Director acknowledged these findings during the observations. The issue was further discussed with the Administrator, the Regional Maintenance Director, and the Maintenance Director during the exit conference held on the same day at 2:40 PM. The report emphasizes that these examples are not exhaustive, suggesting that a thorough inspection of each barrier should be conducted to ensure all penetrations are identified and properly sealed. The penetrations in fire-rated barriers must be sealed with a UL-listed approved system to restore the wall, ceiling, or floor to its original fire or smoke-rated integrity, ensuring the safety of the facility's occupants in the event of a fire emergency.
Plan Of Correction
Corrective Actions The following locations had penetrations sealed with fire stopping on 2/5/2025: A. 100 Hallway smoke barrier. B. 300 Hallway smoke barrier. Identification of Others Potentially Affected The Maintenance Director, or designee, performed a facility-wide assessment of the other fire and smoke barriers to ensure all penetrations are sealed with fire stopping. Systemic Changes The Maintenance Director, or designee, will perform monthly inspections X 3 months of the fire and smoke barriers to ensure all penetrations are sealed with fire stopping. Inspections will continue semi-annually thereafter on an ongoing basis as part of the facility's life safety program. Quality Assurance Results of the monthly fire and smoke barrier inspections will be presented at the monthly QA meetings X 3 months. If substantial compliance is not met after 3 months, monthly inspections will continue, and results will be brought to QA meetings until substantial compliance is met.