Hazardous Areas - Enclosure
Hazardous areas must meet one of the following:
*Contain 1 hour rated enclosure when non-sprinklered
*Sprinkler protected with smoke resistive separation
*Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7
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Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0321
Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one location, affecting one of two floors.
Findings include:
1. Observation on July 12, 2023, ay 11:27 a.m., revealed a large quantity of storage items, located outside the hazardous area enclosures, located within the basement area.
Exit interview with the Facility Administrator at 11:55 a.m., on July 12, 2023, confirmed the hazardous area enclosure deficiency.
| | Plan of Correction - To be completed: 08/05/2023
All materials outside of enclosure will be removed and will be placed in appropriate enclosed approved areas and or discarded. Date to be completed by is 8/5/2023.
Staff education on proper storage guidelines will be completed by 8/5/2023.
Further monitoring to prevent re- occurrence will be done weekly with walk through of basement area by DON or Administrator.
A log sheet will be added to document consistent monitoring of basement area to prevent re-occurrence of this issue.
All monitors are reported to QA committee for reveiw of compliance.
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