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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Findings include:

A. In the 1965 Building Basement, the Emergency Department Waiting Room, which is open to the adjacent Corridor, was observed to lack a smoke detector required by Exception 7. [subpart (b)] to 19.3.6.1.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

A. Hazardous areas not covered by a sprinkler system were observed at which the enclosure walls do not carry a minimum 1 hour fire resistance rating required by 19.3.2.1. and 8.2.2.2. because the walls do not carry a fire resistance rating AND the doors do not carry a minimum 3/4 hour fire rating [see 8.2.3.2.3.1(2)]. Locations observed include (all Second Floor:

1. Former Operating Room 1.

2. Former Operating Room 2.
3. Linen Storage Room.
B. The door to the 1965 Building First Floor Medical Records Room was observed to not carry a minimum fire resistance rating of 3/4 hour as required by 19.3.2.1. and 8.2.3.2.3.1.(2).
C. The following deficiencies were observed relative to the pass-through window at the 1976 Building First Floor Pharmacy, all as prohibited by 19.3.2.1 and 8.2.3.2.3.1(2):
1. The pass-through door was observed to not be self-closing.
2. The pass-through window was observed to not be positive latching.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

1. The exit stairs for the Mobile Technical Unit (trailer) were observed to not be provided with handrails at both sides as required by 7.2.2.4.2.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. The required 2 hour fire rated separation wall between the 1965 and 1976 Building, at the First Floor near the Exit Stair, was observed to not form a complete barrier as required by 7.2.4.3.1. and 8.2.2.2. because

1. The wall does not extend to the underside of the deck as required by 8.2.2.2.

2. Two ducts were observed penetrating the fire barrier which are not equipped with fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.1.1.

Based on staff interview, and document review, not all emergency lighting is maintained in accordance with 7.9.

Findings include:

A. During a review of the facility's building systems test records, it was determined that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3. During an interview held in the 1976 Building First Floor Chapel on the morning of November 24, 2009, the provider's Maintenance Supervisor confirmed this finding.

Based on document review and staff interview, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6.

Findings include:

A. Through document review, it could not be verified that the facility tests fire alarm system components on a periodic basis as required by NFPA 72 1999 7-3.2. , because no certifications are provided by the vendor which confirm the nature and findings of such tests. During an interview held in the 1976 Building First Floor Chapel on the morning of November 24, 2009, the provider's Maintenance Supervisor confirmed this finding.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

Findings include:

A. The 1976 Building Basement Understair Niche, located across the Corridor from the Central Storage Room, was observed to lack a sprinkler head required by NFPA 13 1999 5-1.1.(1).

Based on document review and staff interview, not all portions of the facility's sprinkler system are installed and tested in accordance with NFPA 25.

Findings include:

A. During the document review process sprinkler quarterly flow tests did not show an alarm activation time for comparison to most recent test in accordance with NFPA 1998 25 1-10.3. During an interview held in the 1976 Building First Floor Chapel on the morning of November 24, 2009, the provider's Maintenance Supervisor confirmed this determination.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. At the 1965 Building Basement, a chair used by Emergency Department personnel to triage patients was observed in the Corridor, as prohibited by 19.2.3.3. and 7.1.10.2.1., because it obstructs egress.

Based on random observation during the survey walk-through, not all duct penetrations at smoke barriers are protected against the passage of smoke in accordance with 8.3.5.

Findings include:

A. A duct that penetrates the 1965 Building First Floor smoke barrier wall was observed, above the cross-corridor doors, that is not equipped with a smoke damper required by 8.3.5.1.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

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.

Based on document review and staff interview, not all portions of the facility's emergency electrical system are tested and maintained in accordance with NFPA 99 1999.

Findings include:

A. During the document review process, it could not be determined that monthly testing of the facility's line isolation monitors was being conducted, as required by NFPA 99 3-3.3.4.2 (b), because no records of such tests were available. During an interview held in the 1976 Building First Floor Chapel on the morning of November 24, 2009, the provider's Maintenance Supervisor confirmed this determination.

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:


A. During an interview held in a 1976 Building First Floor Patient Sleeping Room on the afternoon of November 23, 2009 , the provider's Maintenance Supervisor was not able to confirm that each patient bed location on that floor is provided with at least 1 electrical receptacle served by the building emergency electrical system as required by NFPA 70 1999 517-18(a).


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B. During the walk-through electrical panels were observed at various locations which appeared to have directories which were not current and up to date as required by NFPA 70 384-13. Locations include but are not necessarily all locations:

1. Panel EM-1 on the Third Floor.

2. Panel LP-2 on the First Floor.

Based on random observation during the survey walk-through and staff interview, not all elevators within the facility conform with firefighters' service requirements of ANSI/ASME A17.3.

Findings include:

A. The 2 elevators in the 1965 Building were observed to not be equipped with firefighters' recall service as required by ASME/ANSI A17.3. 1993 3.11.3. and ASME/ANSI A17.1 1993 211.3. During an interview held in the Third Floor Corridor on the morning of November 23, 2009, the provider's Maintenance Supervisor confirmed this observation.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Findings include:

A. In the 1965 Building Basement, the Emergency Department Waiting Room, which is open to the adjacent Corridor, was observed to lack a smoke detector required by Exception 7. [subpart (b)] to 19.3.6.1.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

A. Hazardous areas not covered by a sprinkler system were observed at which the enclosure walls do not carry a minimum 1 hour fire resistance rating required by 19.3.2.1. and 8.2.2.2. because the walls do not carry a fire resistance rating AND the doors do not carry a minimum 3/4 hour fire rating [see 8.2.3.2.3.1(2)]. Locations observed include (all Second Floor:

1. Former Operating Room 1.

2. Former Operating Room 2.
3. Linen Storage Room.
B. The door to the 1965 Building First Floor Medical Records Room was observed to not carry a minimum fire resistance rating of 3/4 hour as required by 19.3.2.1. and 8.2.3.2.3.1.(2).
C. The following deficiencies were observed relative to the pass-through window at the 1976 Building First Floor Pharmacy, all as prohibited by 19.3.2.1 and 8.2.3.2.3.1(2):
1. The pass-through door was observed to not be self-closing.
2. The pass-through window was observed to not be positive latching.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

1. The exit stairs for the Mobile Technical Unit (trailer) were observed to not be provided with handrails at both sides as required by 7.2.2.4.2.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. The required 2 hour fire rated separation wall between the 1965 and 1976 Building, at the First Floor near the Exit Stair, was observed to not form a complete barrier as required by 7.2.4.3.1. and 8.2.2.2. because

1. The wall does not extend to the underside of the deck as required by 8.2.2.2.

2. Two ducts were observed penetrating the fire barrier which are not equipped with fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.1.1.

Based on staff interview, and document review, not all emergency lighting is maintained in accordance with 7.9.

Findings include:

A. During a review of the facility's building systems test records, it was determined that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3. During an interview held in the 1976 Building First Floor Chapel on the morning of November 24, 2009, the provider's Maintenance Supervisor confirmed this finding.

Based on document review and staff interview, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6.

Findings include:

A. Through document review, it could not be verified that the facility tests fire alarm system components on a periodic basis as required by NFPA 72 1999 7-3.2. , because no certifications are provided by the vendor which confirm the nature and findings of such tests. During an interview held in the 1976 Building First Floor Chapel on the morning of November 24, 2009, the provider's Maintenance Supervisor confirmed this finding.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

Findings include:

A. The 1976 Building Basement Understair Niche, located across the Corridor from the Central Storage Room, was observed to lack a sprinkler head required by NFPA 13 1999 5-1.1.(1).

Based on document review and staff interview, not all portions of the facility's sprinkler system are installed and tested in accordance with NFPA 25.

Findings include:

A. During the document review process sprinkler quarterly flow tests did not show an alarm activation time for comparison to most recent test in accordance with NFPA 1998 25 1-10.3. During an interview held in the 1976 Building First Floor Chapel on the morning of November 24, 2009, the provider's Maintenance Supervisor confirmed this determination.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. At the 1965 Building Basement, a chair used by Emergency Department personnel to triage patients was observed in the Corridor, as prohibited by 19.2.3.3. and 7.1.10.2.1., because it obstructs egress.

Based on random observation during the survey walk-through, not all duct penetrations at smoke barriers are protected against the passage of smoke in accordance with 8.3.5.

Findings include:

A. A duct that penetrates the 1965 Building First Floor smoke barrier wall was observed, above the cross-corridor doors, that is not equipped with a smoke damper required by 8.3.5.1.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

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.

Based on document review and staff interview, not all portions of the facility's emergency electrical system are tested and maintained in accordance with NFPA 99 1999.

Findings include:

A. During the document review process, it could not be determined that monthly testing of the facility's line isolation monitors was being conducted, as required by NFPA 99 3-3.3.4.2 (b), because no records of such tests were available. During an interview held in the 1976 Building First Floor Chapel on the morning of November 24, 2009, the provider's Maintenance Supervisor confirmed this determination.

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:


A. During an interview held in a 1976 Building First Floor Patient Sleeping Room on the afternoon of November 23, 2009 , the provider's Maintenance Supervisor was not able to confirm that each patient bed location on that floor is provided with at least 1 electrical receptacle served by the building emergency electrical system as required by NFPA 70 1999 517-18(a).


26665


B. During the walk-through electrical panels were observed at various locations which appeared to have directories which were not current and up to date as required by NFPA 70 384-13. Locations include but are not necessarily all locations:

1. Panel EM-1 on the Third Floor.

2. Panel LP-2 on the First Floor.

Based on random observation during the survey walk-through and staff interview, not all elevators within the facility conform with firefighters' service requirements of ANSI/ASME A17.3.

Findings include:

A. The 2 elevators in the 1965 Building were observed to not be equipped with firefighters' recall service as required by ASME/ANSI A17.3. 1993 3.11.3. and ASME/ANSI A17.1 1993 211.3. During an interview held in the Third Floor Corridor on the morning of November 23, 2009, the provider's Maintenance Supervisor confirmed this observation.