Volume 2025 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
■ A two-hour fire rated pipe chase extending from the lower level to the sixth floor mechanical room was open/unsealed to the mechanical room. The two-hour fire-rated barrier at the telephone switch room was missing the front and rear upper wall sections. In the data room, wall seams were taped with a colored tape that was not identified as an approved fire stop product. ■ In the medical-surgical unit, a storage room greater than 50 square feet contained combustibles, which places it in the category of a hazardous room. The room did not have a fire-rated door and was not listed as a hazardous room on the life safety drawings. ■ The life safety drawings display the lab as a hazardous area with a one-hour firebarrier around the perimeter. Based on observation, the entrance door is not fire- ated. ■ The fire door for oxygen storage did not latch. ■ Based on document review, the organization's June 2023 Fire Door Testing Report identified 111 failed doors with 65 doors having been repaired, however, at the time of this survey (2025), 46 doors have not been repaired. No ALSM had been completed for this deficiency. ■ One leaf of the OB unit’s two-hour fire-rated doors did not latch on closure. The materials management department/maintenance shop/main kitchen dish room, two-hour fire-rated door did not latch on closure ■ The organization's annual side-hinged fire door inspection, performed by in-house staff, did not meet the requirements of the NFPA 80 door inspection standard having only four of the eleven required inspection points documented. ■ The pipe chase access fire door near the sterile processing decontamination room was a 30-minute-rated door where a 90-minute rating is required. ■ At stairwell 3 on floor 2, the fire-rated door was provided with panic hardware where fire service hardware is required. Compliance tips for:
■ Identify smoke compartments vs. barriers that require a fire rating on life safety drawings. ■ Schedule inspections above dropped ceilings for gaps or penetrations in smoke and fire barriers. ■ Inventory all fire-rated door assemblies and schedule annual inspection and testing. Many of these will have been tested many times under standard 13.01.01, but this scheduled testing ensures adequate documentation and should result in few failures because of the frequency of testing on environmental rounds. ■ Inspect automatic and other fire-rated doors to ensure that they close fully and latch as intended. ■ Train staff that wall and ceiling penetrations must be sealed. ٝ In fire-rated barriers, the gap must be sealed with fire caulk or otherwise protected with an approved, UL-listed material to protect the integrity of the rating. ٝ Smoke barriers do not require the use of fire-resistant materials when sealing gaps. ■ When considering repurposing a room as a hazardous area, ensure that the space can meet the requirements of NFPA 101-2012: 43.7.1.2(2). ٝ Update life safety drawings to reflect the change. ■ Testing failures must be immediately corrected with an ALSM when repair is pending.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
14.04.09 (CAH) 13.04.09 Frequency of the citation: 14.04.09 56%, 13.04.09 61% Ceilings
Fire-rated barriers are building elements like walls, floors, and ceilings designed to contain fire and required in areas with higher fire risk, such as medical gas storage or large storage rooms. They must meet a specific fire- resistance rating (typically 1 or 2 hours) and use fire-rated materials. Standard 13.04.01 focuses on ensuring the integrity of these barriers. Standard 13.04.02 addresses smoke barriers intended to limit the spread of smoke to allow safe horizontal evacuation. They are required in healthcare smoke compartments and must resist smoke movement for at least one hour but are not necessarily fire-rated for higher-intensity exposure. Standards 14.04.07 and 13.04.07 return to fire-ratings specific to door assemblies and includes requirements for self-closing devices, positive latching hardware and minimal gaps where edges meet and at the floor.
Nerd Newbies (understand the requirement)
Overview of the requirement: Ceilings designed to limit the passage of smoke are free from cracks, holes, and gaps greater than 1/8 inch.
Comment on deficiencies: Compliance is assessed through observation. Surveyors noted issues with:
■ Missing or damaged ceiling tiles. ■ Unsealed ceiling penetrations. ■ Ceiling system integrity. ■ Work above ceilings.
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