Vertical Openings - Enclosure
2012 EXISTING
Vertical openings shall be enclosed or protected per 8.6, unless one of the following conditions exist:
1. Unenclosed vertical openings per 8.6.9.1 are permitted.
2. Unenclosed openings which do not serve as a required means of egress are permitted.
3. Exit access stairs may be unenclosed if they meet the following conditions:
Two stories or less
a. Building is protected throughout by a supervised sprinkler system per 9.7.1.1(1).
b. Total travel distance to outside does not exceed 100 feet.
Three stories or less
a. Occupant load per story does not exceed 15 people.
b. Building is sprinkler protected throughout per 9.7.1.1(1).
c. Building contains an automatic smoke detection system per 9.6.
d. Activation of the sprinkler system or smoke detection system notifies all occupants of the building.
e. Total travel distance to outside does not exceed 100 feet.
Floors that are below the street level and are used for storage or any use other than a business occupancy, shall not have any unprotected openings to the business occupancy floors.
21.3.1, 39.3.1.1, 39.3.1.2
|
Observations:
Name: ENDO ASF - Component: 01 - Tag: 0311
Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be within allowed gap margins, on one of three floors within the component.
Findings include:
1. Observation on July 19, 2023, at 11:10 AM, revealed the fire rated West Stairtower door #12 had gaps, greater than 3/16 inch, at top and latch side.
Interview at the time of the exit conference with the Administrator and Director of Nursing on July 19, 2023, at 1:15 PM, confirmed the stairtower door exceeded the allowed gap margins.
| | Plan of Correction - To be completed: 09/15/2023
Vertical Openings - Enclosure 2012
Existing S 0311
Systematic Changes
The building manager was contacted on
7/20/2023 to assess the gaps in the door to determine whether the door can be repaired or if the door needed to be replaced. Additional vendor, Vale Doors assessed and determined on 7/26/2023
that the door and frame are in order, and will install a new Select SL-11 surface mounted hinge to reach compliance.
Monitoring & Sustaining the Plan
A visual of the stair tower door will be added to the 'ASC Environment of Care (EoC) Rounds' form, where the EoC rounding is conducted and documented on a monthly schedule. The form is filed in the EoC binder where it is easily accessible by administration for state, federal, and accreditation agencies.
Responsible Party & Reporting
The CA is responsible to ensure compliance for this PoC.
Results of compliance with this PoC will be reported to and reviewed by the QAPI
Committee and MEC, and will serve
as a validation that the groups were
informed, and the systemic changes
addressed here were recommended to
the GB for approval at the next scheduled meeting.
|
|
