Volume 2024 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
n The soiled utility room had a positive pressure relationship to the corridor. A negative relationship is required. n Policy states that humidity in the OR is to be maintained between 50-70% relative humidity. The acceptable upper limit is 60% per ASHRAE 170.
14.04.01 Fire-rated barriers Overview of the requirement:
Fire barriers are appropriately rated for their purpose as defined by NFPA 101.
Comment on deficiencies:
Compliance is evaluated by observation. Most deficiencies noted unacceptable, unsealed penetrations in fire-rated barriers, often above the level of the ceiling.
Tips for complianc e:
Many reversed air pressure relationships are corrected at the time of survey. Implement daily monitoring and correction as needed.
Frequency of citation:
33%
Examples of surveyor findings:
n Above the corridor ceiling near the lab, four one-inch diameter penetrations were unprotected through a one-hour rated wall. n In the ceiling above the two-hour fire assembly doors near Shipping and Receiving, the fire putty was coming out revealing a penetration around a bundle of cable wires two inches in diameter. n The two-hour-rated fire doors at the entrance to the emergency department were missing the required latching hardware per NFPA 80-2010.
n Take action as soon as readings indicate the environment does not meet required conditions.
CHAPTER 14: LIFE SAFETY 14.02.01 Fire alarm system – Installation and maintenance Overview of the requirement:
Tips for complianc e:
“Out of sight, out of mind” creates deficiencies. Schedule inspections above dropped ceilings for penetrations that need to be sealed.
Fire alarm systems are installed and maintained per NFPA 72 (2010 edition).
Comment on deficiencies:
Compliance is assessed through observation. Many deficiencies cited issues with accessibility to components of the fire alarm system.
n When conduit or pipes penetrate fire rated barriers, they must be sealed with fire caulk or otherwise protected with an approved UL listed application.
Frequency of citation:
44%
Examples of surveyor findings:
n Access to pull stations was blocked in the main work area (by crash cart), in the ED waiting room (by a couch and end table), and in the main lobby (by the coffee counter). n Smoke detectors are installed closer than 36 inches from air-diffusers. n There is no audible device for the smoke detection system in the physician on-call room. n Recognize that any deficiency with the fire alarm system that cannot be corrected in the same day must prompt an ALSM assessment. n Educate staff to maintain clear access to all components of the fire alarm system. n Review smoke detector locations relative to other features to ensure compliant placement.
14.04.07 Fire-rated door assemblies Overview of the requirement:
Doors and frames in fire-rated assemblies meet the requirements of NFPA 80-2010 and annual testing and inspection is documented. Compliance is assessed through observation and comparison to life safety drawings. Most deficiencies cited problems with latching or missing labels.
Comment on deficiencies:
Tips for complianc e:
Frequency of citation:
33%
Examples of surveyor findings:
n A one-hour fire-rated wall had four 20-minute rated doors without a latching mechanism. n At the only stairwell on the second floor, the exit enclosure door was missing a fire rating label, and it did not latch. n The south stairwell enclosure door on the third floor and the first floor ED soiled utility room doors were missing rating labels. n Door deficiencies noted on last year’s door inspection report have not been corrected. n Ensure all fire-rated door assemblies are appropriately labeled. n Inventory all fire-rated door assemblies and schedule annual inspection and testing. n Fix internally identified deficiencies!
Tips for complianc e:
achc.org | (855) 937-2242 | 41
40
Made with FlippingBook - PDF hosting