Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80)
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Observations: Name: MAIN BUILDING 01-GROVE ST. - Component: 01 - Tag: 0761
Based on document review and interview, the facility failed to maintain, inspect, and test fire doors, in accordance with regulations, on four of four building levels.
Findings include:
Document review on December 20, 2023, at 10:02 a.m., revealed the annual fire door inspection report, dated November 2023, listed door deficiencies for 20 of 133 doors. The facility lacked documentation that corrections were made at the time of the survey.
Interview with the director of facility engineering on December 20, 2023, at 10:02 a.m., confirmed the fire door inspection deficiencies.
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Based on document review and interview during an Onsite Revisit Survey conducted on February 14, 2024, at 9:35 a.m., the facility failed to provide documentation verifying the above door deficiencies were corrected at the time of the survey. However, the facility is in the process of ordering, scheduling, and contracting for the repairs.
Interview with the maintenance supervisor on February 14, 2024, at 9:35 a.m., confirmed the above deficiencies were not corrected.
| | Plan of Correction - To be completed: 03/15/2024
The 7 doors within the TCU tower have been repaired. The 13 doors outside of the TCU tower, beyond the 2 hour separation remain a work in progress. PO has been issued to a qualified service Co, parts have been ordered and repairs are anticipated to be completed by March 15th. The facility has a qualified third party vendor complete annual fire and smoke door inspections. Deficiencies are summarized, quotations for repair are sought and PO's issued. During the interim period between inspections the facility engineering department conducts annual safety and life safety inspections in which smoke and fire doors are inspected. Deficiencies identified by either process will be submitted to facility engineering as a work order request and tracked until completion is validated. Systemic changes are not required as the facility has an excellent program in place. Our goal is to resolve any identified deficiency within 60 days. If deficiencies exceed the 60 day threshold depending on the severity of the deficiency the local fire department may be consulted. All life safety deficiencies including doors are discussed at the facility environment of care committee. If trends are identified the committee will discuss, seek options and implement alternate measures as may be needed to reduce or eliminate future occurrences.
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