Initial Comments:
Name - 01 MAIN BUILDING Component - 01
Facility ID# 151399
Component 01
Main Building
Based on a Recertification/Relicensure Survey completed on May 19, 2021, it was determined that Family Hospice was not in compliance with the following requirements of the Life Safety Code for an existing Hospice health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 418.110 (d).
This is a five story, Type II (222), fire resistive building, that is partially sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Vertical Openings - Enclosure
Name - 01 MAIN BUILDING Component - 01
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Based on observation and interview, it was determined the facility failed to maintain vertical openings, affecting one of five floors.
Findings include:
1. Observation on May 19, 2021, at 8:45 a.m., revealed unsealed penetrations located in the 3rd floor stairwell (now a utility shaft) within the Electrical room.
Interview with Facilities Representative #1 on May 19, 2021, at 8:46 a.m., confirmed the penetrations.
Plan of Correction:Facility will continue to use the FSES
NFPA 101 STANDARD
Subdivision of Building Spaces - Smoke Barrie
Name - 01 MAIN BUILDING Component - 01
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls, affecting two of twenty-four smoke compartments.
Findings include:
1. Observation on May 19, 2021, at 9:15 a.m., revealed an unsealed penetration around an electrical cable located above the 3rd floor, cross-corridor doors on the West side.
Interview with Facilities Representative #1 on May 19, 2021, at 9:16 a.m., confirmed the penetration.
Plan of Correction:Facility will continue to use the FSES
1.Penetration was sealed up the same day after the inspection. 05/19/2021
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