HospitalInspections.org

.A). Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. Locations observed:

1. Stair referred to as Unit A, North Stair contains direct entry to mechanical rooms at two separate levels (3rd and 4th) which does not comply with 7.1.3.2.1.

2. Stair referred to as Unit A, North Stair discharges internally to the first floor through the radiology dept (temporary exit egress due to construction). The Stair exit door on this level opens into the stair which does not comply with 7.2.1.4.3 for the door swing in the direction of egress.

3. Stair referred to as Unit A North Stair directs egress through the radiology dept (temporary exit egress due to construction) with a exterior discharge that does not comply with 7.2.2.2.1 (b) Class B for tread depth.

4. The facility does not comply with 7.7.1 or 7.7.2 for the required number of exits permitted to discharge through areas on the level of exit discharge. Of the five stairs observed, three contain non compliant exit components. Stairs serving upper floor levels discharge as follows:
A. Unit B Central stair discharges to the interior of the building on the first floor.
B. Unit B East Stair discharges to an exit passageway.
C. Unit B West Stair discharges on the first floor to the MOB with a deficient discharge.
D. Unit A Center stair discharges interior to a non compliant exit passageway.
E. Unit A North Stair discharges interior to a non compliant exterior discharge.





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A). 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. Locations observed:

1. Stair referred to as Unit A Center Stair at first floor level - discharges internally to an exit passageway which contains unoccupied storage rooms directly connected to the exit passageway. This does not comply with 7.1.3.2.1 (d) for access from normally occupied spaces.

2. Stair referred to as Unit B West Stair contains an interior vestibule which serves as the temporary Hospital Main Entry and exits to the MOB. The provided Life Safety Floor Plans designate a 2-hour separation between the two buildings. The surveyor observed existing unrated glazing and mullions within the designated 2- hour barrier. Location observed above the pair of cross corridor doors between the two buildings. This does not comply with 19.1.2.1 and 19.1.6.2 for construction type requirements for a Hospital facility.




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A). 4.6.10 Construction, Repair, and Improvement Operations; 4.6.10.1 "Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place."
Hourly fire watches are conducted due to an ongoing construction project (which has been submitted to this Division). Due to this project, the fire alarm system is at various locations and times is shut down. The facility does monitor the system during construction; however, after 3:30pm the fire alarm system is put back on line. Documentation provided by the facility does not indicate the following:

1. A remote station (fire department) acknowledges the system being placed in trouble or when it is back on line.

2. The Fire Watch logs do not indicate deficiencies observed or abated. The Facility lacks a written protocol and schedule for all such measures.

3. The narrative does not describe all measures to be implemented, as well as the frequency with which they are to be conducted nor the manner in which the measures are to be documented.

4. Comments related to changes in the interim life safety measures to remain in place as work toward the project completion occurs are not present.

5. The Surveyor observed no posted evacuation floor plans either permanent or temporary (due to the construction project).




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A). Safety Code for Elevators and Escalators ASME A17.1a - 1994 rule 1206.7 "All elevators provided with firefirghters' service shall be subjected monthly to Phase I recall and a minimum of one-floor operation on Phase II to assure the system is maintained in proper operating order. A written record of findings on the operation shall be made and kept on the premises of said operation".

1. The existing Elevator #10 was referred to as having no automatic fire department recall. This Surveyor observed the Annual inspection report from an outside vender, which indicated that all elevators within the building with the exception of the freight elevator contain both phase I and II fire fighter recall. However, the facility does not comply with 9.4.6 for a monthly documented inspection of their elevators. Upon requesting these documents and stating that a recall test could be conducted, representative for maintenance commented that they had not dealt with the elevators in 4 years. The representative was unable to clarify the primary floor level or the secondary floor level for elevator recall. Therefore, the surveyor did not conduct a test of elevator recall.

.A). Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. Locations observed:

1. Stair referred to as Unit A, North Stair contains direct entry to mechanical rooms at two separate levels (3rd and 4th) which does not comply with 7.1.3.2.1.

2. Stair referred to as Unit A, North Stair discharges internally to the first floor through the radiology dept (temporary exit egress due to construction). The Stair exit door on this level opens into the stair which does not comply with 7.2.1.4.3 for the door swing in the direction of egress.

3. Stair referred to as Unit A North Stair directs egress through the radiology dept (temporary exit egress due to construction) with a exterior discharge that does not comply with 7.2.2.2.1 (b) Class B for tread depth.

4. The facility does not comply with 7.7.1 or 7.7.2 for the required number of exits permitted to discharge through areas on the level of exit discharge. Of the five stairs observed, three contain non compliant exit components. Stairs serving upper floor levels discharge as follows:
A. Unit B Central stair discharges to the interior of the building on the first floor.
B. Unit B East Stair discharges to an exit passageway.
C. Unit B West Stair discharges on the first floor to the MOB with a deficient discharge.
D. Unit A Center stair discharges interior to a non compliant exit passageway.
E. Unit A North Stair discharges interior to a non compliant exterior discharge.





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A). 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. Locations observed:

1. Stair referred to as Unit A Center Stair at first floor level - discharges internally to an exit passageway which contains unoccupied storage rooms directly connected to the exit passageway. This does not comply with 7.1.3.2.1 (d) for access from normally occupied spaces.

2. Stair referred to as Unit B West Stair contains an interior vestibule which serves as the temporary Hospital Main Entry and exits to the MOB. The provided Life Safety Floor Plans designate a 2-hour separation between the two buildings. The surveyor observed existing unrated glazing and mullions within the designated 2- hour barrier. Location observed above the pair of cross corridor doors between the two buildings. This does not comply with 19.1.2.1 and 19.1.6.2 for construction type requirements for a Hospital facility.




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A). 4.6.10 Construction, Repair, and Improvement Operations; 4.6.10.1 "Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place."
Hourly fire watches are conducted due to an ongoing construction project (which has been submitted to this Division). Due to this project, the fire alarm system is at various locations and times is shut down. The facility does monitor the system during construction; however, after 3:30pm the fire alarm system is put back on line. Documentation provided by the facility does not indicate the following:

1. A remote station (fire department) acknowledges the system being placed in trouble or when it is back on line.

2. The Fire Watch logs do not indicate deficiencies observed or abated. The Facility lacks a written protocol and schedule for all such measures.

3. The narrative does not describe all measures to be implemented, as well as the frequency with which they are to be conducted nor the manner in which the measures are to be documented.

4. Comments related to changes in the interim life safety measures to remain in place as work toward the project completion occurs are not present.

5. The Surveyor observed no posted evacuation floor plans either permanent or temporary (due to the construction project).




.

A). Safety Code for Elevators and Escalators ASME A17.1a - 1994 rule 1206.7 "All elevators provided with firefirghters' service shall be subjected monthly to Phase I recall and a minimum of one-floor operation on Phase II to assure the system is maintained in proper operating order. A written record of findings on the operation shall be made and kept on the premises of said operation".

1. The existing Elevator #10 was referred to as having no automatic fire department recall. This Surveyor observed the Annual inspection report from an outside vender, which indicated that all elevators within the building with the exception of the freight elevator contain both phase I and II fire fighter recall. However, the facility does not comply with 9.4.6 for a monthly documented inspection of their elevators. Upon requesting these documents and stating that a recall test could be conducted, representative for maintenance commented that they had not dealt with the elevators in 4 years. The representative was unable to clarify the primary floor level or the secondary floor level for elevator recall. Therefore, the surveyor did not conduct a test of elevator recall.