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: WEST WING - Component: 02 - Tag: 0111
Based on document review, observation, and interview, the facility failed to comply with building rehabilitation requirements for one of one facility.
Findings include:
Document review on December 12, 2023, at 9:41 a.m., revealed the facility updated the fire alarm panel and installed 28 photo smoke detectors, 10 manual pull stations, and seven heat detectors without state approved plans or a granted occupancy from the Division of Life Safety. The facility had multiple "lift cover pull fire alarm" box covers disconnected but not decommissioned, possibly creating confusion in the event of an emergency situation.
Interview with the maintenance director on December 12, 2023 at 9:41 a.m., confirmed the facility had not submitted plans for the equipment.
**************************************** Based on document review and interview during an Onsite Revisit Survey conducted on January 31, 2024, at 11:35 a.m., the facility failed to provide corrective documentation for the above deficiencies.
Interview with the administrator and maintenance supervisor on January 31, 2024, at 11:35 a.m., confirmed the facility could not provide the documentation at the time of the Revisit Survey.
| | Plan of Correction - To be completed: 02/18/2024
After further investigation, Wilkins fire alarm systems confirmed that Swartz repaired the main control panel leaving all existing field devices untouched all in functional, working order. The confusion of adding smoke detectors, pull stations and heat detectors was in a proposed estimate by Swartz Fire Alarms, that never was completed.
Based off of Wilkins information, the proposed estimate provided was not necessary.
Field devices were gradually upgraded to newer addressable type devices over a period of several years. There was no evidence of changing the overall quantity of detection devices or notification appliances or their locations.
Documents are available to review during revisit.
The "lift cover pull fire alarm" box covers disconnected were decommissioned after survey.
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