Non-Compliance with Fire Resistance Rating Due to Excessive Building Height
Penalty
Summary
Surveyors determined that the facility failed to maintain compliance with the fire resistance rating requirements for building construction as outlined in NFPA 101. During document review and observation, it was found that the facility is a five-story building with a basement, classified as Type II (000) unprotected non-combustible construction, and is fully sprinklered. According to the applicable code, this construction type is not permitted to exceed one story, even if sprinklered, but the facility exceeds this limit by three stories. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Directors, who acknowledged that the building's story height does not meet the maximum allowance for its construction type. The deficiency affects the entire facility, as the building's structure does not align with the required fire safety standards for its classification.
Plan Of Correction
On CMS guidance, a Time Limited Waiver will be initiated related to this deficient practice. Subsequently, CMS changed the FSES calculation, relieving health care occupancies of the NFPA standard requiring fire-protective coating for structural steel supports in buildings of five stories or more. A life safety consultant will be contracted to perform an updated FSES related to this deficient practice.