Inaccurate Life Safety Code Floor Plans
Penalty
Summary
The facility was found to be deficient in maintaining accurate portable Life Safety Code Floor Plans. During a document review, it was observed that the floor plans did not include essential information such as smoke barrier walls, fire barrier walls, horizontal exits, and rated rooms like storage rooms, soiled utility rooms, and designated medical gas rooms. Additionally, required exits and shaft walls were not clearly noted on the plans. This deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services.
Plan Of Correction
1) Facility obtained accurate floor plans. 2) ED of construction to Inservice on policy and procedure for ensuring the safe storage of floor plans. 3) Supervisor of Plant Operations or Delegate to complete audits 3x per week x 4 weeks to ensure plans are completed and available in accordance with policy and procedure.