Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11.
20.2.1, 21.2.1, 7.1.10.1
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Observations:
Name: 5910 KIRKWOOD STREET, PGH, PA. 15206 - Component: 01 - Tag: 0211
Based on documentation review and interview, it was determined the facility failed to perform the required annual fire door assembly inspection in one instance, affecting the entire facility.
Findings include:
1. Review of documentation on November 12, 2024, at 8:30 a.m., revealed the facility lacked documentation for an annual fire door assembly inspection, at the time of survey.
Interview with the Facility Maintenance Director on Novemeber 12, 2024, at 8:30 a.m. confirmed the annual fire door assembly inspection documentation was not available.
| | Plan of Correction - To be completed: 11/14/2024
An "Annual Rated Fire Door Inspection" is done every year. The documentation for the 2024 calendar year was located in a different "safety & security" binder.
Documentation has since been added to all ARHC binders that contain information pertaining to safety & security and the facility in general. Inspections of rated fire doors include: condition of door, hardware, door frame, and automatic closure device. Staff member also checks to ensure proper closing of door.
Staff member will ensure that documentation is updated in all binders at the annual inspection going forward.
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