Failure to Obtain Approval for Fire Safety Alterations
Penalty
Summary
The facility was found to be deficient in meeting the minimum standards for operation as required by the Department and other state and local agencies. During a document review, it was observed that in the basement's Main Electrical (switchgear) Room, two heat detectors were programmed into the fire panel, and four Halotron fire extinguishers were installed after the removal of existing ADX Halon units. These alterations and renovations were conducted without obtaining Department-approved plans, as confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) Our vendor will submit plans to the Plan Review Department for approval of modifications to the fire suppression system. 2) No other areas affected. 3) To prevent the potential for reoccurrence, the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of making sure all plans are approved prior to initiating alterations and renovations. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee will review all plans to make alterations and/or renovations and will seek approval from DOH as required prior to following through with said plans. Findings will be reported at the facility QAPI for continued review and recommendations as changes occur.