Deficiencies in Fire Door Maintenance and Inspection
Summary
During a Life Safety Code recertification survey conducted from early to mid-month in 2024, several deficiencies were observed in the maintenance and inspection of fire doors used as means of egress in the facility. Specifically, in the Muhlenberg unit, the double fire door by a certain room did not adjust properly when tested, and another set of double doors left a gap of approximately 1/3 inch between the door meeting edges at the bottom. Additionally, in the Sunset Hall unit, the double doors by another room got stuck on the frame and did not close properly. These observations indicate that the doors were not maintained in accordance with NFPA 101: Life Safety Code and NFPA 80: Standard for Fire Doors and Other Opening Protectives. Further document review revealed that the facility's Fire and Exit Door Checklist, dated late October 2024, included a column for checking each door, but did not verify the 11 specific inspection items required by NFPA 80:5.2.4.2. This lack of detailed inspection documentation suggests that the facility did not ensure comprehensive compliance with the necessary standards for fire door maintenance and inspection. The Engineering Manager acknowledged the issue and mentioned that a vendor had been called to replace one of the problematic doors, while the Senior Director of Operations stated that the checklist would be updated to include the required inspection items.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **Plan of Correction for affected areas** The facility engaged a certified fire door vendor to repair or replace the double fire doors by room [ROOM NUMBER] and the double fire doors by room [ROOM NUMBER] in the Muhlenberg unit. On (MONTH) 10, 2024 the maintenance staff adjusted the double fire doors by room [ROOM NUMBER] in Sunset Hall. The double doors self-close in the frame and are smoke tight. The maintenance staff will complete an annual 11-point inspection of all smoke barriers and fire-rated doors in the building. All doors with deficiencies will be corrected on the spot or scheduled for replacement. **Plan of Correction to identify other areas potentially affected** The facility acknowledges that all residents have the potential to be affected by this practice. Maintenance staff will complete an 11-point inspection of all smoke barriers and fire-rated doors in the building. All doors with deficiencies will be corrected on the spot or scheduled for replacement. **Plan of Correction for system measures to prevent reoccurrence** The Director of Maintenance updated the Policy and Procedure for the annual inspection and testing of Fire Doors. The Policy and Procedure now includes the annual inspection and testing of Fire Doors utilizing a new audit tool including the 11-point inspection criteria required by NFPA 80, 2010 Edition. All maintenance staff will receive additional education by the in-service coordinator/designee and all participants will understand the life safety issues with Inspection and testing of fire doors in accordance with the requirements. The In-Service Coordinator/designee has been assigned responsibility for the education of staff. This education will also be provided to all new maintenance staff and will be reviewed when concerns are identified. The Director of Maintenance or designee will inspect all fire doors monthly and utilize an audit tool to document the findings and report the audit findings to the Quality Assurance/Quality Improvement Committee monthly for a period of six (6) months. **Plan of Correction for monitoring corrective actions** The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of all the audits to the Quality Assurance/Quality Improvement Committee on a monthly basis for 6 months, as well as correction plan if warranted. **Responsibility:** Director of Operations **Compliance Date:** January 27, 2025
Penalty
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