Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Smoke barrier doors shall be a minimum of 1-3/4 inches thick, solid-bonded wood core or equivalent with self-closing or automatic-closing devices in accordance with 21.2.2.4. Latching hardware is not required. Doors are not required to swing in the direction of egress travel.
21.3.7.9, 21.3.7.10
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Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0374
Based on observation and interview, it was determined the facility failed to maintain two smoke barrier separation doors, affecting two of two smoke compartments.
Findings include:
1. Observation on September 9, 2024, between 2:28 p.m., and 2:36 p.m., revealed the following:
a. 2:28 p.m., the single, smoke barrier separation door, located at the Lobby entrance, exhibited a non-rated vision panel.
b. 2:36 p.m., the single, smoke barrier separation door, located in the Pre/Post-Op area, required adjustment to fully latch. The door was equipped with latchinig hardware.
Exit interview with the Facility Administrator on September 9, 2024, at 3:10 p.m., confirmed the smoke barrier separation door deficiencies.
| | Plan of Correction - To be completed: 03/01/2025
A.
1.Purchase and install a new fire rated door without a vision panel.
2. Install date 3/1/2025
3. No systemic changes will be required once doo is compliant.
4. Add new door details to the Fire and Smoke door inventory/testing form to be included in annual testing and inspection.
B.
1. Adjust the automatic-closing device on the door so that it positively latches when the door is ajar ninety degrees.
2. 9/12/2024
3. Educate staff that fire and smoke doors that have an automatic-closing device, must close and positively latch a hundred percent of the time.
4. continue with annual testing and inspection of fire and smoke rated doors.
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