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Based on random observation during the survey walk-through, not all interior finishes comply with applicable requirements of the Life Safety Code. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of compliance can expose occupants to harmful fire and smoke conditions. Findings include:

A. On the afternoon of 6/12/12, wood paneling wall finishes were observed in rooms that could not be confirmed to conform to Class A, B, or C in accordance with Occupancy Chapters and 10.2.3. Locations observed include but may not be limited to the following:

1. The painted plywood at the IT closet on the 3rd floor.

2. The unfinished pegboard at the PT Storage room on the 3rd floor.
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3. The exposed partially painted rigid styrofoam insulation board at Mechanical room 3-B3, "East Mechanical Room" adjacent the Materials Management Conference room.

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. These deficiencies could affect all persons in the smoke compartment, because the lack of smoke detectors could result in delayed activation of the fire alarm system and smoke compromising the facility's exit access corridors. Findings include:

A. The 1st floor Patient Registration Reception Workroom was observed on the morning of 6/13/12 to lack smoke detection in accordance with 19.3.6.1 Exception No. 1.

Based on random observation during the survey walk-through on 6/13/12, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels. Findings include:

A. The access doors at the Ground floor level of the communicating stair of the east wing were observed not to be labeled as fire resistance rated door assemblies to comply with 19.3.1.1.

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 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition. Findings include:

A. The 1st floor Emergency Dept. room 18 was observed on the morning of 6/13/12 to be utilized for storage. The door to this room was not self-closing to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

Based on random observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building. Findings include:

A. The 2nd floor east stair was observed on the morning of 6/12/12 to have a door latch which did not always engage to provide positive latching.

B. The 1st floor stair near the Pharmacy was observed to have the door not self-closing to a latched condition under fire alarm activation.

Based on random observation during the survey walk-through, not all exit or exit access doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building. Findings include:

A. The 3rd floor closets at Materials Management rooms 3-B330 & 3-B331 were observed on the afternoon of 6/12/12 to be equipped with hardware (dead bolt keyed both sides) which required a key to operate the door in non-compliance with 7.2.1.5.4.

B. Multiple rooms on the 2nd floor (utilized as offices) were observed on the afternoon of 6/13/12 to be equipped with hardware (dead bolt locks and latching hardware) which required more than one releasing operation to operate the doors when locked in non-compliance with 7.2.1.5.4..

C. The Ground floor Business Services Suite was observed on the afternoon of 6/13/12 to be equipped with hardware (dead bolt lock and latching hardware) which required more than one releasing operation to operate the doors when locked in non-compliance with 7.2.1.5.4.

Based on random observation during the survey walk-through, not all 2-hour barriers are constructed in accordance with 8.2.3. These deficiencies could affect all persons in the facility, by preventing the barriers from providing the intended separation protection. Findings include:

A. The 2-hour barrier at the MOB was observed on the morning of 6/13/12 to be equipped with a rubber smoke seal to close the excessive gap between the pair of doors. The doors were not provided with a coordinator device and the seal prevented the doors from closing to a latched condition when not closed in proper sequence. It was not confirmed that the rubber seal was listed as meeting the 90 minute rating for the doors.

B. The pair of doors at the south end of the 1st floor Lobby in the 2-hour barrier were not labeled as meeting the required 90 minute rating. They were labeled as "Similar to a 90 minute fire door but not carry a label because of a specification deviation(s) from manufacturer's approvals."

C. The double egress cross corridor doors just west of the Main entry lobby did not close to a latched condition upon self-closing during fire alarm testing.

Based on random observation during the survey walk-through on the morning of 6/13/12, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way. Findings include:

A. The following exit discharge locations were observed to lack fixtures/lighting with more than one lamp/fixture equipped with instantaneous type lighting connected to the emergency power system to comply with 7.8.1.4. Lighting appeared to be HID type which requires restrike and/or warm-up period to provided illumination.

1. At the exterior exit discharge stair near 1 West.

2. At the exit discharge from the connector corridor near the MOB.

3. At the exit discharge from the Loading Dock.

4. At the exit discharge from the corridor which accesses the Loading Dock.

Based on random observation during the survey walk-through, exit signs were not fully visible to designate the path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building. Findings include:

A. 2nd floor exit signage observed on the morning of 6/12/12 on the south side of the smoke barrier cross corridor doors at the west corridor was not visible due to other signage.

B. 1st floor exit signage observed on the morning of 6/13/12 at the east end of the corridor south of the Emergency Dept. was not visible from the west. A directional sign was provided at the intersection of the corridors but appeared to be turned 90 degrees.

C. 1st floor exit signage observed on the morning of 6/13/12 at the south end of the intersecting corridor from the Lobby was not visible due to other signage.

D. Ground floor corridor observed on the morning of 6/13/12 south of Kitchen/Cafeteria lacks exit signage at the single swing cross corridor control doors south of the smoke barrier cross corridor doors. These single swing doors did not swing in the direction of exit travel. The occupant load was not confirmed for compliance with with 7.2.1.4.2.

E. The Ground floor Lobby observed on the morning of 6/13/12 has only one designated exit at the south end. The signage provided is not visible from the north end conference room area. The open stair is not identified as an exit path.

Based on record review it was determined that the facility failed to adequately document that fire drills are being conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required. Findings include:

A. During a record review it was determined that quarterly fire drills are conducted, but documentation does not appear complete to substantiate the requirements of NFPA 101 Section 19.7.1.2.

1. Fire Policy 9850-208 approved 4/18/12 Titled as Fire Plan-Code Red-Fire Response Plan, P. 6 of 6 states under paragraph "8. Fire Drills...staff response will be observed at the drill location and: Adjacent compartments, the compartment above and below the drill location." However, only a single response form is created for the drill event rather than a response document for each area observed. Response documents do include sign-in sheets with names and department location presumed to be a list of those participating in the drill but it is not easily determined from the list that the names represent the smoke compartment of the drill, the smoke compartments adjacent the drill and the smoke compartments above or below the smoke compartment of activation.

2. It is not clear from the response documentation that the alarm activation is tranmitted and received by the fire dept./central station in accordance with 19.7.1.2.

3. Documentation reviewed was identified as "drills". It was not clear that actual fire alarm activations were documented with response documentation or recorded as actual fire/smoke events.

Based on random observation during the survey walk through, not all areas of the building fire alarm system are installed in accordance with NFPA 72 (1999). This could effect all building occupants if the fire alarm system does not initiate an alarm without delay or the components can not be located during a fire emergency. Findings include:

A. Smoke detection is installed at a partial lower ceiling level (old ceiling level where the majority of the ceiling has been removed) rather than at the high point of the ceiling area to comply with 2-3.4.3.1.

1. At Mechanical room 1A.
2. At Mechanical room 2A.


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B. Some of the manual pull stations were not properly located within 5' of the exit as required by NFPA 72, Section 2-8.2.2.

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). Findings include:

A. The skylight area of the Cafeteria is a ceiling cavity area which relies upon activation of sprinkler protection provided as sidewall sprinklers at the perimeter of the cafeteria space. It was not clear how the sidewall sprinkler coverage complied with NFPA 13-1999, 5-4.2 relative to the large volume of space contained within the skylite ceiling configuration without sprinkler protection.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99. This deficiency could affect all occupants of the smoke compartment they are located in because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials. Findings include:

A. Four medical gas tanks were observed being stored with combustibles within 5'-0" not in compliance with NFPA 99 1999 8-3.1.11.2(c)(2) at the Heart Center Storage room.

Based on random observation during the survey walk-through on the afternoon of 6/12/12, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99-1999. Findings include:

A. During the survey of the 3rd floor LTC unit, the medical gas piping observed above the ceiling near the Linen room and near the Nurse Station was observed without labeling to identify the medical gas in accordance with 4-3.1.2.14 (a) and the piping was not separated from dissimilar metals to comply with 4-3.1.2.9. The extent of these conditions were not determined and may be typical throughout.

B During the survey of the 3rd floor near the cross corridor doors of the smoke barrier at the east end of the west wing, the copper piping observed above the ceiling was observed without labeling to identify the if this was medical gas piping to comply with 4-3.1.2.14 (a).

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.

B. The Vestibule at the exterior exit from 1 West is provided with floor-to-ceiling glass at the exterior wall in straight line allignment from the interior doors. The arrangement of the exit path requires a 90 degree turn to exit the building. It was not confirmed how the glass at this exterior window assembly complies with the applicable components of the Consumer Product Safety Commission 16 CFR Part 1201, including compliance with the requirements pertaining to impact loads when a handrail/guard is not provided at the window wall.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch. Findings include:

A. Life safety panels EL in the elevator equipment room, LSDP-2 was serving a UPS system, and LS3 and other life safety panels throughout the main building are serving loads other than those specifically allowed by NFPA70, Section 517-32.

B. Some of the critical panels were serving loads other than those allowed on the critical power system. for example critical panel C1B had circuits feeding air handling units and a walk in cooler that should be fed from an equipment panel. This does not meet the requirements of NFPA70, Section 517-33.

C. The fire alarm circuit breakers in the Life Safety Panels should be marked red and have a locking device on the breakers to comply with NFPA-72, Section 1-5.2.5.

D. Some lighting and receptacles in the generator room are required to be fed from the life safety panel to comply with NFPA-70, Section 517-32. They are presently served from an equipment panel in the mechanical room.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999). Findings include:

A. Normal power receptacles were not provided in C-section rooms, and operating rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

B. The metal piping systems, (med gas and gas), are not bonded as required by NFPA 70-250.104(c). This could create a shock hazard for all building occupants.

C. The C-section room and operating rooms are not equipped with battery powered lighting as required by NFPA-99, Section 3-3.3.2.1.2(a)5e.

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed. Findings include:

A. The surveyor observed that the elevator machine rooms were equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

B. Each elevator machine room should have at least one GFCI protected outlet to meet the requirements of NFPA-70, Section 620-23.

C. The lighting disconnects in each of the machine rooms needed proper labeling showing where the life safety panel and overcurrent device serving each unit was located to comply with NFPA-70, Section 620-53.