Volume 2024 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
13.04.01 Fire-rated barriers 13.04.07 Fire-rated door assemblies
Many reversed air pressure relationships are corrected at the time of survey. Implement more frequent monitoring and immediate correction to avoid citations.
Overview of the requirement:
Fire-resistance-rated barriers are walls and doors designed to limit the spread of fire from one area of a building to another. They must be appropriately rated for their purpose as defined by NFPA 101 and annual testing and inspection of door assemblies is documented. Compliance is evaluated by observation and comparison to life safety drawings. Penetrations in fire-rated barriers reduce or negate their effectiveness. Most deficiencies noted unacceptable, unsealed penetrations in fire-rated barriers or doors that did not positively latch.
13.03.01 Water-based fire protection system: Installation and maintenance Overview of the requirement: Hospitals constructed (or with areas renovated) since the adoption of the 1991 Life Safety Code requires the installation of water-based sprinkler systems. Once installed, systems must be maintained to the original installation requirements.
Comment on deficiencies:
Comment on deficiencies:
Compliance is assessed through observation and interview. Deficiencies were cited for interior features blocking sprinkler heads and the use of sprinkler pipes as support for other utilities.
Frequency of citation:
13.04.01: 27%; 13.04.07: 41%
Examples of surveyor findings:
n There were floor penetrations in the electrical rooms with improper firestop product application in the four-inch conduit sleeves. The use of the product allowed gaps and did not promote smoke resistance. The specification sheet for the product does not describe this type of application. n The laundry room wall construction does not continue to the deck above and therefore does not meet one-hour fire-barrier wall construction requirements. n Two rooms designated as hazardous rooms are not constructed to meet one- hour fire-barrier standards. n The fire-rated wall between the boardroom and dry storage had penetrations filled with combustible spray foam instead of fire-rated material. n A first floor fire-barrier double door leaf did not close and latch. n The fire door in a fire-rated room was propped open with a rubber wedge. n The two-hour fire-rated double door’s bottom latching hardware at the OB unit entrance was nonfunctioning due to missing the holes in the floor. n The annual fire door inspection identified 70 doors as failed. Approximately 50% remained unrepaired without evidence of an alternative life safety measure (ALSM) in place. n Wall penetrations must be properly sealed with approved UL-listed materials. n Schedule inspections above dropped ceilings for gaps or penetrations in fire barriers. n Once a fire-rated wall or door is penetrated, the gap must be sealed with fire caulk or otherwise protected with an approved, UL-listed material to protect the integrity of the rating. n Inspect automatic and other fire-rated doors to ensure that they close fully and latch as intended. n 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.
Frequency of citation:
28%
Examples of surveyor findings:
n In multiple storage locations, shelving (or materials stored on shelves) was located less than 18 inches from the bottom of the sprinkler heads. This clearance is required for the sprinklers to be effective in distributing water. n Network cables/low voltage cables were observed to be supported by sprinkler piping. n Sprinkler heads were missing their escutcheon plates. n Paint was observed on some sprinkler heads and escutcheons. n Sprinkler heads were heavily soiled with dust in multiple locations and with grease and corrosion in the kitchen. n Include visual inspection of sprinklers on regular environmental rounding. n Train staff to report issues related to maintenance/cleanliness of sprinklers. n 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. n Ensure that contractors understand that cabling cannot rest on sprinkler piping, even above a dropped ceiling.
Tips for compliance:
Tips for compliance:
Sprinkler head escutcheons cover the gap between the sprinkler head and the ceiling tile or drywall. When missing or improperly fitted, the resulting gap may delay activation of smoke detectors and/or the sprinkler head as heat and smoke rise above the ceiling.
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