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HOPEDALE HOSPITAL
No Description Available
Tag No.: K0044
Based on random observation and staff interview accompanied by the Head of Maintenance, not all duct penetrations at designated 2 hour rated fire barriers are protected against the passage of fire and smoke to comply with 8.3.5. This condition could allow fire and smoke to travel from one building addition to an adjacent addition during a fire emergency affecting patients, staff and visitors in both compartments from reaching an exit discharge.
The finding is:
A. 07/30/2013 at 1:50pm It was determined that 2-hour barrier separations (designated on the facility floor plan) containing duct penetrations lack damper installations to comply with NFPA 90A 3-4. Separations are located between building additions.
New 2-6-2014
The facility's Plan of Correction indicated that this work was to be complete by 1-16-2014. As of 2-5-2014 it was not complete.
No Description Available
Tag No.: K0104
Based on random observation and staff interview accompanied by the Head of Maintenance, not all duct penetrations at smoke barriers are protected against the passage of smoke to comply with 8.3.5. This condition could allow fire and smoke to travel from one smoke compartment to an adjacent compartment during a fire emergency affecting patients, staff and visitors in both compartments from reaching an exit discharge.
The finding is:
A. 07/30/2013 at 1:35pm it was noted that a duct penetrating a designated smoke barrier (facility floor plan) could not be determined to be equipped with a smoke damper due to the lack of an access panel to comply with 8.3.5.1 and NFPA 90A 2.3.4.1. Location observed: Main Level 1963 building smoke barrier above the corridor separation adjacent to the MRI, X-Ray Wing.
New 2-6-2014
The facility's Plan of Correction indicated that this work was to be complete by 1-16-2014. As of 2-5-2014 it was not complete.
No Description Available
Tag No.: K0130
A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.