Name: MAIN BUILDING - Component: 01 - Tag: 0372
Based on observation and interview, it was determined the facility failed to maintain the rating of the smoke barrier walls, in one of two smoke zones within the component.
1. Observation on May 28, 2019, at 10:45 AM revealed a partially-sealed conduit and data cable bundle above the smoke barrier walls, at Zone A.
Interview at the time of the exit conference with the Maintenance Director and the Administrator on May 28, 2019, at 11:45 AM confirmed there was a partially-sealed penetration.
| ||Plan of Correction - To be completed: 07/19/2019|
The facility will maintain the rating of the smoke barrier in the two smoke zones within the component.
1. The partially-sealed conduit and data cable bundle above the smoke barrier walls at Zone A were sealed with fire calking by the Facilities Department on May 29, 2019.
2. The Facilities Department on May 30, 2019 performed an audit of the facility to determine if there were any penetrations in the smoke zones. No additional penetrations were found.
3. An audit will be performed weekly by the Director of Facilities/designee to determine if there are penetrations and to seal any penetrations that are found. The audit will be shared with the NHA on a weekly basis for review and any action plan.
The Director of Facilities/designee will audit any work performed by outside vendors at the completion of the work to ensure that any penetrations created by the vendor are sealed and report findings of the audit to the NHA for review and any action plan.
4.The weekly audits performed by the Director of Facilities/designee and report of the work performed by any outside vendor will be reviewed at the Quality Assurance/Performance Improvement Committee which meets quarterly. The next scheduled meeting is set for July 19, 2019.