Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards, specifically affecting two of nine smoke compartments. During an observation on March 19, 2025, at 11:40 a.m., it was noted that the smoke barrier doors leading to rooms 100-132 (ICF-1) had an excessive gap between the meeting edges. This gap compromised the doors' ability to resist the passage of smoke, which is a critical safety requirement. An interview conducted with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director at 12:30 p.m. on the same day confirmed the presence of the excessive gap. This deficiency indicates a failure to ensure that the smoke barrier doors met the necessary standards to prevent smoke passage, as required by the 2012 NFPA 101 code for existing buildings.
Plan Of Correction
1. The smoke door on ICF 1 is being evaluated by the vendor for repair or replacement if indicated. 2. No other smoke doors were identified with gaps. 3. The Director of Plant operations or designee will audit smoke barrier doors monthly x 3 months. 4. Audits will be taken to the safety committee and submitted to the QAPI committee for review of findings and further interventions are warranted.