Initial Comments:
Name - TENANT SPACE Component - 01
Facility ID# 50811501
Component 01
Based on a Relicensure Survey completed on January 14, 2025, it was determined that BMMSA Heart And Vascular Center of The Main Line was not in compliance with the following requirements of the Life Safety Code for an New Ambulatory health care occupancy.
This is a three-story, Type II (000), unprotected and non-combustible building, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Subdivision of Building Spaces-Smoke Barrier
Name - TENANT SPACE Component - 01
Subdivision of Building Spaces - Smoke Barrier Construction
2012 NEW
Smoke barriers shall be constructed to provide at least a 1 hour fire resistance rating and constructed in accordance with 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations of fully ducted HVAC systems.
20.3.7.5, 20.3.7.6, 8.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of two floors.
Findings include:
Observation on January 14, 2025, at 8:40 a.m., revealed on the second floor Mechanical/Server Room, unsealed penetrations around a data wire and plumbing pipes.
Exit interview with the Facility Administrator and Maintenance Director on January 14, 2025, at 9:15 a.m., confirmed the penetrations.
Plan of Correction:The penetrations that were exposed around the data wire and plumbing that were discovered during our survey on 1/14/2025 were caulked immediately following the survey on 1/14/2025, with Fire-Gard Caulk Elastomeric Intumescent Firestopping Sealant.
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