Not-For-Profit Acute Care Hospital

This facility is part of a large national healthcare system, that LSS is the national provider for passive fire protection services (e.g. dampers, doors, firestopping). LSS was contracted to perform a Firestop and Above Ceiling Survey to assist the facility in preparing for their upcoming CMS and Joint Commission Surveys. The Survey would consist of LSS locating above ceiling Code Violations, such as open and/or unsealed penetrations in the fire and smoke barriers, open / uncovered electrical boxes (e.g. Junction Boxes), and loose wires hanging, or wrapped around sprinkler pipes, and sprinkler pipes missing supports.

How LSS Helped the Client:

  • Helped the facility establish compliance with The Joint Commission, CMS, and NFPA (101, 99, 70, etc.)
  • Removed cables attached to the sprinkler pipes and holders using zip-ties to connect to the other above ceiling supports and replace missing “4×4” Junction Box Covers with new “J-Box” covers.
  • Discussed with facility engineer a schedule of repairs for the barriers to lessen likelihood of future TJC and CMS Violations
  • Provided the facility with a Statement of Conditions for above ceiling, including a listed of approved UL Firestop Systems to be installed in the open and unsealed penetrations.
    • Provided cost estimated for LSS to perform the firestop installation of the UL Firestop Systems, so the facility could judge cost of in-sourcing v. outsourcing.

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