Subdivision of Building Spaces - Smoke Compartments
Smoke compartments do not exceed 25,000 square feet in size.
Every story shall be divided into not less than 2 smoke compartments unless one of the following conditions occur:
Facility is less than 5,000 square feet protected by an approved smoke detection system
Facility is less than 10,000 square feet protected by an approved, supervised sprinkler system per 9.7
Adjoining occupancy is used as a smoke compartment if all of the following are met:
a. Separating wall is 1 hour fire resistive rated
b. Doors in the 1 hour rated wall at 1-3/4 inches thick
c. Doors in the 1 hour rated wall are self-closing
d. Windows in the 1 hour rated wall are fixed fire window assemblies per 8.3
e. The ambulatory health care facility is less than 22,500 square feet
f. Access from the ambulatory health care facility is unrestricted to another occupancy
20.3.7.2, 21.3.7.2
|
Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0371
Based on observation and interview, it was determined that the facility failed to ensure that common fire walls were maintained free of unsealed penetrations, affecting one level.
Findings include:
Observations made on June 26, 2024, at 10:12 a.m., revealed unsealed penetrations in common fire walls in the equipment storage room.
Interview at the exit conference with the Administrator and Maintenance Director on June 26, 2024, at 10:30 a.m., confirmed the unsealed penetrations.
| | Plan of Correction - To be completed: 07/09/2024
All penetrations were inspected and sealed with UL listed fire caulk by July 9th, 2024.
Facilities have created an above ceiling permit process. This permit applies to work that involves any fire rated assemblies, smoke barrier and walls, fire walls, concrete floors, ceiling decks etc.
When a permit is issued, a designee from Facilities will review each penetration in the barriers identified to ensure all sleeves are in the closed position and all fire stopping is in place with no gaps. Any contractor or vendor personnel engaging in work that will require penetrating fire rated assemblies must obtain an above ceiling permit from Facilities before any penetration work can begin.
Facilities will inspect all fire rated and smoke partitions on a quarterly basis. Documentation of any repairs will be kept with above ceiling permits.
Any deficiencies identified during inspections will be reported to the Safety Officer and Environment of Care Committee.
|
|
