Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)
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Observations: Name: BUILDING 02 - Component: 02 - Tag: 0111
Based on observation and interview, it was determined the facility failed to maintain building rehabilitation requirements in one location, affecting one of three floors.
Findings include:
1. Observation on January 25, 2024, at 11:44 a.m., revealed the exit discharge door, located closest to the Staff Lounge, had recently been changed to "delayed egress," without notifying the Division of Safety Inspection/Plan Review.
Exit interview on January 25, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Mnager and the Facility Administrator, confirmed the building rehabilitation requirments deficiency.
| | Plan of Correction - To be completed: 03/05/2024
1. Administrator reported "delayed egress," of staff lounge door to Division of Safety Inspection/Plan Review.
2. The Maintenance Director/Designee will conduct an initial audit to verify if any other facility changes need to be reported to the Division of Safety Inspection/Plan Review.
3. Regional Director of Operations will educate Administrator and Maintenance Director on required reportable incidents.
4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify if any other facility changes need to be reported to the Division of Safety Inspection. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.
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