Failure to Submit Construction Plans for Fire Safety Review
Penalty
Summary
The facility failed to submit required plans and specifications to the Bureau of Fire Services for a construction project involving newly built walls between the Activities Office and Dietary Office. During an observation, a newly constructed diagonal wall in the Activities Office and a straight wall in the Dietary Office were identified, with a void area approximately three feet wide where suppression coverage was unknown. No documentation or plans for this construction were provided to the surveyor upon request or by the end of the survey. This deficiency was confirmed through interviews with the Facility Maintenance Director and Facility Maintenance staff at the time of observation.
Plan Of Correction
K1001. The Maintenance Director and/or designee will remove the constructed wall between the Activity Office and Dietary. The Administrator will review regulation K100 and provide education to the Maintenance team on the requirements. The Maintenance Director and/or designee will conduct weekly rounds of the community spaces to ensure no lack of suppression coverage, and no new construction is completed without prior approval. Results of the audits will be brought to the Quality Assurance Performance Improvement meeting monthly for review. The Committee will be responsible for any changes to the auditing process. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.