Volume 2025 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
■ The hospital did not have documentation of: ٝ Check valve 5-year inspection.
13.04.01 Fire-rated barriers 13.04.02 Smoke barriers 14.04.07 (CAH) 13.04.07
ٝ Pressure gauge monthly inspection. ٝ Main drain quarterly and annual tests. ٝ Control valve annual exercise. ٝ 50-year standard response (SR) sprinkler head replacement.
Fire-rated door assemblies
■ The annual fire sprinkler system inspection is incomplete. Portions are documented (pipe and hanger/sprinkler head inspection), however the remaining requirements per NFPA 25 are not documented, including spare sprinkler head inventory and wrench, free of foreign materials/ corrosion, proper clearance, and system information signs. ٝ Annual control valve exercise documentation did not include a procedure or pass/fail result to confirm completion of the requirement. ٝ Annual back flow preventer: No documentation of testing completed in the past twelve months. ٝ Quick response sprinkler head replacement: No documentation of the original installation date of the QR sprinklers or replacement/testing schedule was provided. Standard response sprinkler head replacement: No documentation of the original installation date of the SR sprinklers or replacement/testing schedule. ■ Signage for the fire department connection outside Entrance 7 was missing. Compliance tips for:
Frequency of the citation: 13.04.01 52%; 13.04.02 26%; 14.04.07 78%; 13.04.07 45%
Overview of the requirement: Fire and smoke barriers represent levels of containment to facilitate evacuation and to limit the spread of fire. Fire-rated walls and doors must be appropriately rated for their purpose as defined by NFPA 101. Any penetrations in smoke or fire barriers must be sealed. Annual testing and inspection of door assemblies is documented. Comment on deficiencies: Compliance is evaluated by observation and comparison to life safety drawings. Surveyors noted issues with: ■ Fire and smoke barrier integrity. ■ Hazardous room separation. ■ Fire door condition and operation. ■ Fire door inspection and maintenance. ■ Life safety documentation and coordination. Examples of ACHC Surveyor findings: ■ In the cardiovascular interventional care unit, three 2-inch, and one 4-inch unsealed conduit penetrations were noted above the double smoke doors and 15 additional unsealed penetrations were observed in walls. ■ The smoke barrier wall separating the cardiovascular interventional unit and the antepartum unit at the doors does not reach the decking, rendering the smoke barrier noncompliant. ■ There are unsealed, 3-inch penetrations in two-hour fire barrier walls: ٝ In the ceiling above door #1233. ٝ In the ceiling of the third floor IT closet. ■ A 6-inch by 10-inch open penetration was observed in the two-hour fire rated barrier wall between the generator room and the automatic transfer switch room on the ground floor.
As with fire alarm systems, fire protection systems include a large number of components that work in coordination. Buildings and construction renovations require sprinklers. Installed systems, whether required or not, must meet NFPA 13 and NFPA 25 standards. In addition to review of testing documentation, location and upkeep of components is frequently cited for observable noncompliance. ■ Include visual inspection of sprinklers on regular environmental rounding. ■ Regularly audit storage areas for the height and location of items stored on high shelving to ensure 18 inches of clear space to the bottom of sprinkler heads. ■ Schedule testing for all components of water-based systems in accordance with Life Safety Code requirements. ■ Train staff to report issues related to maintenance/cleanliness of sprinklers. ■ Missing or improperly fitted sprinkler escutcheons may delay activation of smoke detectors and/or the sprinkler head as heat and smoke rise. ■ Ensure that contractors understand that cabling cannot rest on sprinkler piping, even above a dropped ceiling.
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