Observations
Based on an observation during a physical plant inspection, the facility failed to ensure an additional fire extinguisher for each 2,000 square feet.
A physical plant inspection was conducted on May 31, 2016 at approximately 1:30 PM.
Based on the floor plan given to the licensing specialist, the total square footage of the second floor being used as the outpatient facility is 5,395. The facility failed to have more than two portable fire extinguishers for each 2,000 square feet.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A third fire extinguisher has been installed which brings the property into compliance with the 1 extinguisher per 2,000 square foot regulation. All three existing extinguishers have been inspected as of June 2016. Corresponding photographs of each extinguisher and current inspection tag have been forwarded to (DOH) by Division Director on 6/8/2016.
Moving forward, the Division Director (overseen by the Operations Manager) will be responsible for ensuring 3 operable fire extinguishers are on the premises at all times and that all have valid current inspection tags. |