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Tag No.: K0255
Based on observations made during the survey of the facility between the hours of 10:00 am and 3:00 pm, while accompanied by the CEO, Director of Quality, and the Director of Plant Ops it was observed that the facility was not in compliance with the following:
The "AS-BUILT" drawings did not readily identify existing SMOKE COMPARTMENTATION - which is a CODE requirement for the "subdivision" of the building into multiple SMOKE COMPARTMENTS that are separated by 1 hour fire/smoke barrier walls.
Not having this Life Safety Information (information on the required "subdivision" construction) readily identified is not acceptable for a Hospital. Hospitals need this level of information for multiple reasons: SAFETY of patients, TRAINING of staff, MAINTAINING INTEGRITY of rated construction, and REGULATORY REVIEW of their facility.
Provide an accurate "LIFE SAFETY PLAN" drawing showing the proper subdivision of the building. Accurately Show and Identify each existing SMOKE COMPARTMENT. In addition, all other types of existing fire & smoke rated construction information required by Code & Hospital Licensing Rules shall be readily identified and shown in the updated documentation.