Deficiencies in Hazardous Area Enclosures
Penalty
Summary
The facility failed to maintain three hazardous area enclosures, affecting two of three floors. On the 1st floor, the Holding Room door did not latch into the frame when tested, compromising the enclosure's integrity. Additionally, the Elevator machine room on the same floor was improperly used for storage, containing six plastic folding tables. On the 3rd floor, in the Sycamore area, the Soiled Linen room had unsealed wall penetrations due to damage, further compromising the enclosure's effectiveness. These deficiencies were confirmed during an exit interview with the Facility Administrator and Facilities Manager.
Plan Of Correction
1. The first floor holding room door mechanism has been repaired. The 6 plastic folding tables have been removed from the first-floor elevator machine room. Third floor Sycamore Soiled Linen penetration has been sealed and repaired. 2. NHA will in-service Maintenance Director on maintaining enclosed areas free of hazards and penetrations. 3. Maintenance Director/designee will complete a random weekly audit x 4 then monthly x 3. 4. Audits will be reported to QAPI for further recommendations.