HospitalInspections.org

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Based on observation and interview, the facility failed to ensure all smoke barriers were sealed to prevent the passage of smoke, as required by NFPA 101, 2003.

Observations on 07/25/16 from 2:30pm to 4:30pm, revealed holes and unsealed pipe penetrations above the ceiling at several locations at corridor walls and cross-corridor door walls.

In an interview during the afternoon of 07/25/16, the Facility Management Director stated that stated that all holes and unsealed penetrations would be properly filled to prevent the passage of smoke.

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Based on observation and interview, the facility failed to ensure that there were no unsealed penetrations at all rated walls, which does not meet the requirements of:

NFPA 101, 2003: 8.3.5.1 ..... Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.

Observations on 07/25/16 from 2:30pm to 4:30pm, revealed there were unsealed holes and penetrations above the ceiling in the fire rated walls, such as the walls of Soiled Linen Rooms and Janitor's Closets.

In an interview during the afternoon of 07/25/16, the Facility Management Director stated that the holes and penetrations would be properly sealed to achieve the required fire rating.

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