Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 530025 (X3) Date Survey Completed 11/07/2011
Name of Provider or Supplier Ivinson Memorial Hospital Street Address, City, State 255 N 30th, Laramie, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
K0104 LIFE SAFETY CODE STANDARD
CFR(s): NFPA 101

Penetrations of smoke barriers by ducts are protected in accordance with 8.3.6.


This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to ensure duct work that penetrated smoke barriers was protected by a smoke damper on 1 of 3 floors. The findings were: Observation on 11/3/11 at 11:44 AM showed a vent, from a mechanical fan, passed through the wall between the first floor electrical room #2 and the boiler room. At the time of observation the facility supervisor reported the fan exhausted hot air from the electrical room into the boiler room. He also reported he was unaware duct work penetrating smoke barrier walls was required to be provided with a smoke damper. Reference: NFPA 101, 2000 Edition, 19.3.7.3; 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke barrier. b. It shall be made by an approved device that is designed for the specific purpose.