Multiple Occupancies - Sections of Ambulatory Health Care Facilities
Multiple occupancies shall be in accordance with 6.1.14.
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following:
* The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access.
* They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating.
Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following:
* Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab.
* Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches.
* Doors are self-closing and are kept in the closed position, except when in use.
* Windows in the barriers are of fixed fire window assemblies per 8.3.
Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44
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Observations:
Name: MAIN BUILDING 01 (CLASS C) - Component: 01 - Tag: 0131
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of the tenant separation wall, affecting one of one tenant separation wall.
Findings include:
1. Observation on May 3, 2023, at 10:00 a.m., revealed an unsealed penetration around data wires above the door to the office/exam room by the restroom.
Interview at the exit conference with the Administrator on May 3, 2023, at 11:00 a.m., confirmed the unsealed penetration.
| | Plan of Correction - To be completed: 05/28/2023
Building owner, Gabriel Property, Inc., performed repairs on unsealed penetration around data wires located in ceiling outside employee restroom on May 24, 2023. Material used for the repair was 3M Brand "Fire Barrier Sealant" product #CP25WB+. Data sheet for 3M product states the Fire Barrier Sealant CP25WB+ has fire stop up to 4 hours in accordance with UL 1479, meets UL 1479 aging requirements, is L rated, STC (ASTME E90 and ASTM E413:54). When tested in STC 54-rated wall assembly CP25WB+ is used for sealing single or multiple through penetrations in fire rated construction and is used in mechanical, electrical and plumbing applications to fire stop openings created by the following penetrations in fire-rated floors, floor/ceilings or walls: metallic pipe, plastic pipe, conduit, power and communication cable, cable trays, busways, combos, insulated pipe and HVAC duct penetrations. It is also used to fire stop blank openings and static construction joints. System No. W-L-1474.
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