Unsealed Smoke Barrier Penetrations in F-Unit and D-Unit
Summary
The facility failed to ensure proper maintenance of smoke barrier doors in two of its six smoke barriers, specifically in the F-Unit and D-Unit. During the Life Safety Code recertification survey, it was observed that the F-Unit smoke barrier had an unsealed cable wire passing through the wall, and the D-Unit smoke barrier had an unsealed data wire passing through the wall. The Maintenance Director, during an interview, admitted to being unaware of these unsealed penetrations and acknowledged the importance of properly sealed smoke barriers to prevent the spread of smoke and fire. The facility's documentation indicated that the smoke barriers were checked quarterly, with the last check completed on 12/20/2024, but the Maintenance Director had not followed up on this check. The facility's Smoke Wall Checks inaccurately documented the D Wing and F Wing as being in good condition.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 Wall penetrations were repaired on 1/14/2025. Maintenance Staff was inserviced on the importance of sealing any wall penetrations when completing work. The Director of Environmental Services will monitor compliance with a smoke wall penetration audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
Penalty
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