Observations
Based on a physical plant inspection and an interview with the facility director, there was no evidence of a smoke detector at this facility.
The findings include:
A physical plant inspection and an interview with the facility director was conducted on August 10, 2009. There was no evidence of a smoke detector at the facility. The facility director stated that the smoke detectors were in the ducting, but as of October 8, 2009, the facility director failed to produce any evidence regarding the existence and location of those smoke detectors.
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Plan of Correction
Although the facility's blueprints designated smoke detection units throughout the duct work, it was suggested that this system may not be effective for all types of possible fires within the facility.
Therefore, the facility director purchased 3 smoke detector units and had them installed on October 13th. One was installed in the waiting room area and the other two were installed in the east and west wing corridors of the suite.
The facility director will ensure that these smoke detectors will be tested monthly and be maintained as needed. |