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
|
Observations:
Name: MAIN - Component: 01 - Tag: 0131
Based on observation and interview, it was determined the facility failed to maintain the rating of the tenant separation wall, one of one smoke zone within the component.
Findings include:
1. Observation on March 13, 2023, at 11:00 AM, revealed the rated door, in the 1-hour fire-rated tenant separation, had gaps, greater than 1/8 inch.
Interview with the DON on March 13, 2023, at 11:00 AM, confirmed the rated door gaps were greater than 1/8 inch.
| | Plan of Correction - To be completed: 05/01/2023
1. The clinical director called Capital Doors and Hardware on 03/22/2023 to come onsite to inspect the center's door that failed inspection due to the door gap being greater than 1/8".
2. A representative from Capital doors and Hardware arrived onsite on 3/23/2023 to inspect the door and to determine what was needed in order to become compliant with the door gap requirements for fire rated doors.
3. The NGP Gap 90 material was ordered on 03/23/2023 with a stated delivery turn around time of approximately three weeks. Once the kit arrives, our building contractor will install. All work is anticipated to be completed by 05/01/2023.
4. Moving forward the annual door inspection of all of the center's fire rated doors will continue. Any issues found would be addressed at the time of each inspection or at the discovery of any failure to meet door requirements. All testing results will be appropriately documented and kept in the Fire door inspection log book.
|
|
