HospitalInspections.org

A) (New 12/16/09): From direct observation the surveyor finds that the 2nd Floor Imaging Reception and Waiting Area is also used as a patient holding area (two patients in gowns were observed in the area open to the corridor; one was on a gurney). This use of the corridor does not comply with 19.3.6.1. See also K048 and K130

What are the interim measures in place for this deficiency?

Based on random observation during the survey walk through, not all exit stair components are constructed or maintained as fire resistive assemblies to comply with 19.3.1.1.

A. The finding is that, based on random observation the surveyor finds that an exit discharge enclosure (that serves an exit stair) does not provide a continuous protected path of escape to comply with 19.3.2. A designated 2-hour fire resistant exit passageway (shown on an un-revised facility floor plan) does not comply with 7.1.3.2.1. Surveyor noted that the exit passageway was not continuous and enclosed, allowing the designated exit stair to discharge to the interior exit access corridor. Facility floor plan shows a pair of cross corridor doors to the west of the stair that were not present during the walk-through. Location observed: Center bldg., first floor, center corridor adjacent to Psych Holding, outpatient services and Lab.

1) The surveyor finds that the east end of the Center Building has a 2nd and 3rd Floor that is served for the exit stair cited. The stair does not comply with 7.7.1 and/or 7.7.2 of NFPA 101. (12/16/09) Identify the current IDPH Project # 8864 in the PoC and revise the completion date, as needed.

2) Corrected 12/16/09

A) (Modified 07/15/10): Accurate as built construction documents and/or accurate master plan documents that accurately identify: fire walls and smoke walls (along with the associated fire ratings), exit enclosures including exit stairs and exit passageways, shaft enclosures and ratings, size of smoke compartments and locations and sizes of suites, were not available on site.

1) Deleted 7/15/10

2) The 1st Floor of the West Building has a C-section Unit that is identified as a suite. The pair of corridor doors at the west perimeter of the suite have latching hardware that does not function.

a) Deleted per PoC statement - 12/16/09
b) Corrected 12/16/09
c) Corrected 12/16/09

3) (New 12/16/09): All suites (including areas and boundaries of each suite) are not clearly identified on the above referenced plans. (examples: Nuc Med, Imaging Suite and another suite to the north are clearly identified on the 2nd Floor. Is the surgical unit a suite or is there a corridor running through it?) 07/15/10 - Revise per any imaging suite to be created.

4) (New 12/16/09): Exit access corridors are not clearly identified.

5) Deleted 7/15/10

6) Revise Life Safety plans for new stair arrangement, when completed.

Center Building Induction Units: Based on staff interview this building has a high pressure induction ventilation system of which the supply to the individual terminal units are through the floor from below and the penetrations are not protected with fire dampers. Through interview it could not be determined that the fire resistive rating of the floor is maintained with the current installation. (NFPA 90A, 1999, 3-3.2).

The 1st and 2nd Floor induction units are supplied from a Basement Level Mechanical Room. The 3rd Floor, 4th Floor and 5th Floor induction units are supplied from a 3rd Floor Mechanical Room.

See inspection letter of 7/19/10 - need to inspect floors above 1 - 5.

West Building:

Based on direct observation the facility failed to provide fire dampers for through the floor duct penetrations supplying the duct riser for the induction ventilation terminal units on 1st, 2nd & 3rd floors. (NFPA 90A, 1999, 3-3.4.4)

Based on staff interview it could not be determined that the vertical shafts containing the duct riser for the induction ventilation terminal units are of construction providing the minimum fire resistance rating of 1 hour. (NFPA 90A, 1999, 3-3.4.1)

See project inspection letter of 07/19/10

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. Deleted 7/15/10

1. Deleted 7/15/10

2. Modified 07/15/10: Fire watch rounds are conducted only once for each shift. There is a construction project in the Center Building. There is particle board on the floor of this project. There is an open, unenclosed shaft where a stair is being removed. A portion of the fire alarm has been disabled for this project. The 2nd and 3rd Floor of the Center Building currently have only one exit.
The surveyor finds that the frequency of the fire watch was not sufficient sufficient for this project.

A) (New 12/16/09): From direct observation the surveyor finds that the 2nd Floor Imaging Reception and Waiting Area is also used as a patient holding area (two patients in gowns were observed in the area open to the corridor; one was on a gurney). This use of the corridor does not comply with 19.3.6.1. See also K048 and K130

What are the interim measures in place for this deficiency?

Based on random observation during the survey walk through, not all exit stair components are constructed or maintained as fire resistive assemblies to comply with 19.3.1.1.

A. The finding is that, based on random observation the surveyor finds that an exit discharge enclosure (that serves an exit stair) does not provide a continuous protected path of escape to comply with 19.3.2. A designated 2-hour fire resistant exit passageway (shown on an un-revised facility floor plan) does not comply with 7.1.3.2.1. Surveyor noted that the exit passageway was not continuous and enclosed, allowing the designated exit stair to discharge to the interior exit access corridor. Facility floor plan shows a pair of cross corridor doors to the west of the stair that were not present during the walk-through. Location observed: Center bldg., first floor, center corridor adjacent to Psych Holding, outpatient services and Lab.

1) The surveyor finds that the east end of the Center Building has a 2nd and 3rd Floor that is served for the exit stair cited. The stair does not comply with 7.7.1 and/or 7.7.2 of NFPA 101. (12/16/09) Identify the current IDPH Project # 8864 in the PoC and revise the completion date, as needed.

2) Corrected 12/16/09

A) (Modified 07/15/10): Accurate as built construction documents and/or accurate master plan documents that accurately identify: fire walls and smoke walls (along with the associated fire ratings), exit enclosures including exit stairs and exit passageways, shaft enclosures and ratings, size of smoke compartments and locations and sizes of suites, were not available on site.

1) Deleted 7/15/10

2) The 1st Floor of the West Building has a C-section Unit that is identified as a suite. The pair of corridor doors at the west perimeter of the suite have latching hardware that does not function.

a) Deleted per PoC statement - 12/16/09
b) Corrected 12/16/09
c) Corrected 12/16/09

3) (New 12/16/09): All suites (including areas and boundaries of each suite) are not clearly identified on the above referenced plans. (examples: Nuc Med, Imaging Suite and another suite to the north are clearly identified on the 2nd Floor. Is the surgical unit a suite or is there a corridor running through it?) 07/15/10 - Revise per any imaging suite to be created.

4) (New 12/16/09): Exit access corridors are not clearly identified.

5) Deleted 7/15/10

6) Revise Life Safety plans for new stair arrangement, when completed.

Center Building Induction Units: Based on staff interview this building has a high pressure induction ventilation system of which the supply to the individual terminal units are through the floor from below and the penetrations are not protected with fire dampers. Through interview it could not be determined that the fire resistive rating of the floor is maintained with the current installation. (NFPA 90A, 1999, 3-3.2).

The 1st and 2nd Floor induction units are supplied from a Basement Level Mechanical Room. The 3rd Floor, 4th Floor and 5th Floor induction units are supplied from a 3rd Floor Mechanical Room.

See inspection letter of 7/19/10 - need to inspect floors above 1 - 5.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. Deleted 7/15/10

1. Deleted 7/15/10

2. Modified 07/15/10: Fire watch rounds are conducted only once for each shift. There is a construction project in the Center Building. There is particle board on the floor of this project. There is an open, unenclosed shaft where a stair is being removed. A portion of the fire alarm has been disabled for this project. The 2nd and 3rd Floor of the Center Building currently have only one exit.
The surveyor finds that the frequency of the fire watch was not sufficient sufficient for this project.