Improper Signage Placement on Egress Doors
Summary
During a recertification survey, it was observed that egress doors equipped with delayed egress locking mechanisms did not have the required signage as per NFPA 101 standards. The signage, which should be located on the door leaf adjacent to the release device in the direction of egress, was instead installed on the walls adjacent to the egress doors. This placement does not comply with the specified requirements for visibility and accessibility in emergency situations. The deficiency was identified during the Life Code survey conducted on February 12, 2025, between 9:00 AM and 3:00 PM. In a subsequent interview on February 13, 2025, the Director of Maintenance acknowledged the issue and stated that the appropriate egress signages would be ordered and installed on the egress doors. The lack of proper signage could potentially hinder the effectiveness of the delayed egress locking mechanisms in an emergency.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 I. Corrective Immediate Action The Director of Plant Operations has ordered ICON construction company that is still under contract, to order and install Emergency Egress signage on newly installed fire exit doors, that is ADA compliant, on all emergency fire doors on all units including the basement to comply with: 2012 NFPA 101: 19.2.2.2.4, 7.2.1.6.1.1 10NYCRR 711.2(a)(1) II. Identification of Other Areas a. A visual observation has been made by the Director of Plant Operations to identify areas of the facility that may be affected by the same practice. b. All areas that have been affected by the same practice have been noted and communicated to the contractor for immediate remediation. III. Education The Director of Plant Operations will in-service the maintenance staff as to the requirements of 2012 NFPA 101: 19.2.2.2.4, 7.2.1.6.1.1, 10NYCRR 711.2(a)(1) to identify and prevent future practices of this type. IV. QA Monitoring The Director of Plant Operations/Designee will monitor practices and record findings during weekly fire door/emergency egress preventive maintenance/life safety rounds monthly for the next 6 months. Logs will be kept in the Maintenance Director’s Office. Any negative findings will be immediately brought to the Director of Plant Operations for remediation. The Plant Operations Director will bring any negative findings to the QAPI committee monthly. V. Person Responsible for Corrective Action Director of Plant Operations
Penalty
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