Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9
Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)
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Observations: Name: A,B & NEW - Component: 01 - Tag: 0321
Based on observation and interview, it was determined the facility failed to maintain hazardous area doors, to be within the allowed gap margins and positively latch in frame, in two of three smoke zones within the component.
Findings include:
1. Observation on February 14, 2024, between 12:05 PM and 12:50 PM, revealed hazardous area doors exceeded minimum gap margins, at the following locations:
a. 12:05 PM, Soiled Utility Room door, by Glow Room, top exceeded 3/16 inch; b. 12:33 PM, Laundry Room, Washroom, left leaf, top exceeded 3/16 inch; c. 12:50 PM, New Wing, Boiler Room door, top and latch side exceeded 3/16 inch.
Interview at the time of the exit conference with the Director of Operations and Administrator on February 14, 2024, at 2:15 PM, confirmed hazardous area doors exceeded the allowed gap margins.
2. Observation on February 14, 2024, between 12:35 PM and 12:37 PM, revealed hazardous area doors failed to close and positively latch in the frame, at the following locations:
a. 12:35 PM, Laundry Room, left leaf, inoperable door closure; b. 12:37 PM, Laundry Room, right leaf, inoperable coordinator.
Interview at the time of the exit conference with the Director of Operations and Administrator on February 14, 2024, at 2:15 PM, confirmed hazardous area doors failed to close and positively latch.
| | Plan of Correction - To be completed: 04/05/2024
The Soiled Utility Room door, by Glow Room, has been adjusted to reduce the gap to less than 3/16 inch. The Laundry Room, Washroom, left leaf, has been adjusted to reduce the gap to less than 3/16 inch. The New Wing, Boiler Room door and frame will be replaced and requires a TLW. The expected completion date of installation will be no later than 06/04/2024. The New Wing, Boiler Room door will have intumescent edge seal placed until the installation of the new door and frame is completed. The Laundry Room, left leaf and right leaf, have been adjusted to be operable.
All other hazardous area doors will be checked in the facility for proper closure and the gap between the door and doorstop will not exceed minimum gap margins.
Director of Operations or designee will complete monthly audits on all hazardous doors to ensure hazardous doors properly close and the gap between the door and doorstop will not exceed minimum gap margins.
The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
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