Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
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Observations: Name: MAIN BUILDING - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor doors, affecting one of ten smoke compartments within the component.
Findings include:
1. Observation on January 24, 2024, at 11:13 AM, revealed four unprotected penetrations in the door to the Social Services Office, on the Glen Side, where door closing hardware was removed.
Interview with the Facilities Director on January 24, 2024, at 11:13 AM, confirmed the unprotected penetrations of the corridor door.
| | Plan of Correction - To be completed: 02/23/2024
K-0363 (E) Corridor- Doors This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to ensure penetrations are not present in the buildings doors. 1. Doors penetrations were repaired using fire rated materials as per door penetrations guidelines. 2. Doors throughout the facility were checked to ensure no penetrations are present. 3. Education completed with Maintenance staff regarding monitoring doors are free from penetrations. 4. Maintenance Director or designee will check door for penetrations each time a work order is completed for door hardware. That check will be recorded. Update on penetrations will be presented at QAPI X 2 months.
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