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100 MCGREGOR STREET

MANCHESTER, NH 03102

No Description Available

Tag No.: K0025

19.3.7.3, NFPA 101, LIFE SAFETY CODE
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

8.3.2, NFPA 101, LIFE SAFETY CODEContinuity: Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review, observation, and interview the facility failed to ensure that the smoke barriers are continuous.

Findings include:

Record review during tour of the life safety compartmentation diagram of the building revealed that smoke barriers are one hour partitions as well as having other one hour and two hour fire rated partitions present.

Observation during tour on 2/9/12 at approximately 11:15 a.m. with Staff C (Maintenance Director) and Staff D (Maintenance Manager) revealed that the smoke barrier separation in the area of E231 is not continuous between the top of the smoke barrier wall and the underside of the ceiling deck.

Interview during tour on 2/9/12 with Staff C and Staff D at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0027

18.3.7.6, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

8.3.4.1, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

A.8.3.4.1, NFPA 101, LIFE SAFETY CODE
The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies.

8.3.4.3, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

18.2.2.2.6, NFPA 101, LIFE SAFETY CODE
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

A.18.2.2.2.6, NFPA 101, LIFE SAFETY CODE
It is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient observation by the staff of an institution. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices activated by the methods described, regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2, NFPA 101, LIFE SAFETY CODE
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Based on record review, observation, and interview revealed that smoke barrier doors are not properly installed and/or maintained.

Findings include:

Record review during tour of the life safety compartmentation diagram of the building revealed that smoke barriers are one hour partitions as well as having other one hour and two hour fire rated partitions present.

Observation during tour on 2/8/12 at approximately 2:55 p.m. with Staff C (Maintenance Director) and Staff D (Maintenance Manager) revealed the following:

1. The smoke door assembly located at the bathroom of the New England Heart Institute on B Level in the 2003 Building is not a self-closing door.

Interview during tour between 2/8/12 with Staff C and Staff D at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0027

19.3.7.6, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.3.4.1, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

A.8.3.4.1, NFPA 101, LIFE SAFETY CODE
The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies.

8.3.4.3, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

19.2.2.2.6, NFPA 101, LIFE SAFETY CODE
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

A.19.2.2.2.6, NFPA 101, LIFE SAFETY CODE
It is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient supervision by the staff of a facility. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices actuated by the methods described regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2, NFPA 101, LIFE SAFETY CODE
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Based on record review, observation, and interview revealed that smoke barrier doors are not properly installed and/or maintained.

Findings include:

Record review during tour of the life safety compartmentation diagram of the building revealed that smoke barriers are one hour partitions as well as having other one hour and two hour fire rated partitions present.

Observation during tour between 2/8/12 and 2/9/12 with Staff C (Maintenance Director) and Staff D (Maintenance Manager) revealed the following:

1. The wood double smoke door assembly located on A Level in the 1978 Building located near A541 has more than 1/8 inch gap between the meeting edges of the door assembly.

2. The smoke door assembly located on C level of the 1978 Building located at the Family Waiting Room of the Cardiac Medical Unit is not a self-closing door.

Interview during tour between 2/8/12 and 2/9/12 with Staff C and Staff D at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0029

19.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

8.4.1.3, NFPA 101, LIFE SAFETY CODE
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that self-closing doors in hazardous areas operate properly.

Findings include:

Observation during tour on 2/8/12 at approximately 2:00 p.m. with Staff C (Maintenance Director) and Staff D (Maintenance Manager) revealed that one of the door leafs in the self-closing double fire door assembly failed to close completely due to the coordinator not functioning properly and preventing the leaf from closing at Dry Goods Storage on B Level of the 1978 Building.

Interview during tour on 2/8/12 at the time of discovery with Staff C and Staff D confirmed the findings.

No Description Available

Tag No.: K0034

18.2.1, NFPA 101, LIFE SAFETY CODE
General: Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

7.2.2.5.3, NFPA 101, LIFE SAFETY CODE
Usable Space: There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Based on observation and interview the facility failed to ensure that usable spaces in enclosed stairwells are not accessible from within the enclosed stairwell.

Findings include:

Observation during tour on 2/8/12 at approximately 1:25 p.m. with Staff C (Maintenance Director) and Staff D (Maintenance Manager) revealed that a sprinkler room is located in Stairwell 2 on A Level and in the 2003 Building is accessible from within the enclosed stairwell.

Interview during tour on 2/8/12 with Staff C and Staff D at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0044

18.2.2.5, NFPA 101, LIFE SAFETY CODE
Horizontal Exits: Horizontal exits complying with 7.2.4 and the modifications of 18.2.2.5.1 through 18.2.2.5.6 shall be permitted.

7.2.4.3.1, NFPA 101, LIFE SAFETY CODE
Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)

8.2.3.2.4.2, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review, observation, and interview the facility failed to ensure that penetrations in fire barriers are properly sealed.

Findings include:

Record review during tour of the life safety compartmentation diagram of the building revealed that smoke barriers are one hour partitions as well as having other one hour and two hour fire rated partitions present.

Observation during tour on 2/8/12 at approximately 3:20 p.m. with Staff C (Maintenance Director) and Staff D (Maintenance Manager) revealed that the two hour rated fire barrier in the area of rooms 19 and 20 in the ICU located in the 2003 Building has at least two unsealed penetrations.

Additionally, portions of smoke barriers and fire barriers in the new portions of the 2003 building have sealed penetrations present sealed with caulking and/or other sealants.

Interview during tour on 2/8/12 with Staff C and Staff D revealed the following:

1. The facility has no documentation of fire stopping materials and manufacturer specifications used in the building for repairing fire rated barriers.

2. The facility is in the process of correcting penetrations to fire rated barriers without manufacturers specifications present for the fire stopping materials that are used.

No Description Available

Tag No.: K0044

19.2.2.5, NFPA 101, LIFE SAFETY CODE
Horizontal Exits: Horizontal exits complying with 7.2.4 and the modifications of 19.2.2.5.1 through 19.2.2.5.4 shall be permitted.

7.2.4.3.8, NFPA 101, LIFE SAFETY CODE
All fire doors in horizontal exits shall be self-closing or automatic-closing in accordance with 7.2.1.8. Horizontal exit doors located across a corridor shall be automatic-closing in accordance with 7.2.1.8.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that fire barrier doors function appropriately.

Findings include:

Observation during tour on 2/9/12 at approximately 10:20 a.m. with Staff C (Maintenance Director) and Staff D (Maintenance Manager) revealed that one of the two leafs of the double leaf fire door assembly fails to close in the assembly located in the fire barrier separation of the 1956 building from the 1978 building on D Level.

Interview during tour on 2/9/12 with Staff C and Staff D at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0052

18.3.4.1, NFPA 101, LIFE SAFETY CODE
General: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4, NFPA 101, LIFE SAFETY CODE
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature, is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review and interview the facility failed to ensure that components of the fire alarm system are properly maintained.

Findings include:

Record review of fire alarm vendor reports during tour on 2/7/12 revealed that the fire alarm inspection report dated 9/23/11 documents that the audio visual devices failed to operate at the following locations in the 2003 Building (labeled as "2004 CMC BLDG" in the fire alarm inspection report):

1. Level A in "Necleau Medicine Hallway": 2 audio visual devices.

Interview during tour between 2/7/12 and 2/9/12 with Staff C (Maintenance Director) confirmed that the audio visual devices have not been repaired.

No Description Available

Tag No.: K0052

19.3.4.1, NFPA 101, LIFE SAFETY CODE
General: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4, NFPA 101, LIFE SAFETY CODE
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature, is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review and interview the facility failed to ensure that components of the fire alarm system are properly maintained.

Findings include:

Record review of fire alarm vendor reports during tour on 2/7/12 revealed that the fire alarm inspection report dated 9/23/11 documents that the audio visual devices failed to operate at the following locations in the 1978 Building:

1. Level B in East Mechanical Room: 3 audio visual devices.

2. Level B in Loading Dock/Store Room Hallway: 2 audio visual devices.

Interview during tour between 2/7/12 and 2/9/12 with Staff C (Maintenance Director) confirmed that the audio visual devices have not been repaired.

No Description Available

Tag No.: K0076

4-3.1.1.1, NFPA 99, HEALTH CARE FACILITIES
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.5.2.1, NFPA 99, HEALTH CARE FACILITIES
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation and interview the facility failed to ensure proper storage of medical gas cylinders.

Findings include:

Observation during tour on 2/8/12 at approximately 2:20 p.m. with Staff C (Maintenance Director) and Staff D (Maintenance Manager) revealed that the Cylinder Room located in the area of the loading dock on B Level contains in excess of 3000 cubic feet of medical gas stored which includes the following:

1. One group of 4 large cylinders which are secured with a single chain.

2. One group of 9 large cylinders which are secured with a single chain.

3. One group of 4 large cylinders which are secured with a single chain.

Observation during tour on 2/9/12 at approximately 9:45 a.m. with Staff C and Staff D revealed that there was one free standing medium sized oxygen cylinder in the nourishment room located on the C100 wing of C Level.

Interview during tour on 2/8/12 and 2/9/12 with Staff C and Staff D confirmed the findings at the time of discovery.

No Description Available

Tag No.: K0104

18.3.7.3, NFPA 101, LIFE SAFETY CODE
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

8.3.6.1, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review, observation, and interview the facility failed to ensure that smoke barriers are properly maintained.

Record review during tour of the life safety compartmentation diagram of the building revealed that smoke barriers are one hour partitions as well as having other one hour and two hour fire rated partitions present.

Observation during tour on 2/8/12 at approximately 1:05 p.m. with Staff C (Maintenance Director) and Staff D (Maintenance Manager) revealed that the smoke barrier in "Moms Place" located in level F is in the process of having penetrations repaired by Staff E (General Maintenance) and Staff F (Carpenter) without referencing manufacturers specifications for applying the product to penetrations based on product, barrier construction, the type of penetrating item, and ensuring that the product is appropriate for the characteristics of each individual penetration.

Interview during tour on 2/8/12 with Staff C and Staff D revealed the following:

1. The facility has no documentation of fire stopping materials and manufacturer specifications used in the building for repairing fire rated barriers.

2. The facility is in the process of correcting penetrations to fire rated barriers without manufacturers specifications present for the fire stopping materials that are used.

No Description Available

Tag No.: K0104

18.3.7.3, NFPA 101, LIFE SAFETY CODE
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

8.3.6.1, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review, observation, and interview the facility failed to ensure that smoke barriers are properly maintained.

Record review during tour of the life safety compartmentation diagram of the building revealed that smoke barriers are one hour partitions as well as having other one hour and two hour fire rated partitions present.

Observation during tour on 2/8/12 at approximately 2:50 p.m. with Staff C (Maintenance Director) and Staff D (Maintenance Manager) revealed that the one hour rated smoke barrier in the area of Scheduling (B741) located in the 2003 Building has at least two unsealed penetrations.

Additionally, portions of smoke barriers and fire barriers in the new portions of the 2003 building have sealed penetrations present sealed with caulking and/or other sealants.

Interview during tour on 2/8/12 with Staff C and Staff D revealed the following:

1. The facility has no documentation of fire stopping materials and manufacturer specifications used in the building for repairing fire rated barriers.

2. The facility is in the process of correcting penetrations to fire rated barriers without manufacturers specifications present for the fire stopping materials that are used.

No Description Available

Tag No.: K0104

18.3.7.3, NFPA 101, LIFE SAFETY CODE
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

8.3.6.1, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review, observation, and interview the facility failed to ensure that smoke barriers are properly maintained.

Record review during tour of the life safety compartmentation diagram of the building revealed that smoke barriers are one hour partitions as well as having other one hour and two hour fire rated partitions present.

Observation during tour on 2/9/12 with Staff C (Maintenance Director) and Staff D (Maintenance Manager) revealed that portions of smoke barriers and fire barriers on E Level in the renovated areas of the 1956 building have sealed penetrations present sealed with caulking and/or other sealants.

Interview during tour on 2/8/12 with Staff C and Staff D revealed the following:

1. The facility has no documentation of fire stopping materials and manufacturer specifications used in the building for repairing fire rated barriers.

No Description Available

Tag No.: K0104

19.3.7.3, NFPA 101, LIFE SAFETY CODE
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

8.3.6.1, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review, observation, and interview the facility failed to ensure that smoke barriers are properly maintained.

Record review during tour of the life safety compartmentation diagram of the building revealed that smoke barriers are one hour partitions as well as having other one hour and two hour fire rated partitions present.

Observation during tour between 2/8/12 and 2/9/12 with Staff C (Maintenance Director) and Staff D (Maintenance Manager) revealed the following:

1. At least one unsealed penetration of the one hour rated smoke barrier is present at the Gift Shop Vendor area located on A level in the 1978 building.

2. At least one unsealed penetration of the one hour rated smoke barrier is present at the Wheelchair Storage Area near Stairwell 1 located on A level in the 1978 building.

3. At least one unsealed penetration of the one hour rated smoke barrier is present at the Hospital Personal Storage area near Transcription located on C level in the 1978 building.

4. At least one unsealed penetration of the one hour rated smoke barrier is present at the area of E231 located on E level.

5. At least one unsealed penetration of the one hour rated smoke barrier is present at the area of E403 located on E level.

6. Portions of smoke barriers and fire barriers in the existing portions of the 1956 building and in the 1978 building have sealed penetrations present sealed with caulking and/or other sealants.

Interview during tour on 2/8/12 with Staff C and Staff D revealed the following:

1. The facility has no documentation of fire stopping materials and manufacturer specifications used in the building for repairing fire rated barriers.

2. The facility is in the process of correcting penetrations to fire rated barriers without manufacturers specifications present for the fire stopping materials that are used.