HospitalInspections.org

K017

A) 1) Corrected 09/19/12

B) Four of four floors of the 1989 Building have a plenum return air system and do not comply with 19.3.6.2.1 of NFPA 101. In most portions of each floor every room communicates above the ceiling to every other room with a plenum return air system. This plenum return air system communicates to the nurse's station and rooms around the nurse's station on each floor. None of the rooms on each floor communicate directly to the exit access corridors, except at the nurse's stations. The nurse's station on the 2nd, 3rd and 4th floors are open to the exit access corridor of each floor.

1) The East Wing/smoke compartment on the 2nd, 3rd and 4th Floors have rooms that are separated from the exit access corridor in accordance with 19.3.6.2.1, exception # 1.

However, the smoke compartment has deficiencies cited under K104 and the shaft enclosure at the end of the wing (next to the stair) is deficient - see K067. These issues will affect how K017 is corrected in the adjacent, non-complying smoke compartments.

2) The other smoke compartment on 2nd, 3rd and 4th Floors incudes the nurse's station. elevator foyer and the West Wing. The nurse's station communicates to all rooms through a plenum return air system and the nurse's station communicates to the entire exit access corridor in this smoke compartment. This arrangement does not comply with any part of 19.3.6.2.1 and does not comply with 19.3.6.2.2 (the exit access corridor is not separated from all other spaces by smoke tight construction).

3) Sleeved unducted openings above the ceilings in some of the rooms identified above have fire dampers installed in sleeves that match the wall thickness. These openings are not protected with smoke dampers with smoke detectors that are designed to maintain a smoke tight separation between all such spaces and the exit access corridors in accordance with 19.3.6.2.2. The extent of this condition could not be determined. Full access to all rooms could not be provided; the were occupied by patients.

4) Sleeved unducted openings above the ceilings in some locations (some of which are designated smoke barriers, other are not in smoke barriers) have smoke dampers installed in sleeves that match the wall thickness. These openings are not protected with smoke dampers with smoke detectors that are designed to maintain a smoke tight separation between all such spaces and the exit access corridors in accordance with 19.3.6.2.2. Smoke detection installed below or above ceilings on these floors are minimal or non-existent.

5) The 1st Floor corridor wall at Classroom 115 is also a designated smoke barrier. The wall has a plenum return air transfer opening above the ceiling. A fire damper is installed in the opening instead of a smoke damper. The wall is not smoke tight to the deck above in accordance with 19.3.6.2.2. The plenum return air opening in the wall lacks a smoke damper and smoke detection.

6) The 1st Floor Administration Office has a wall that stops at the ceiling. All of the spaces in this area have plenum return air openings in the ceilings. The Administration Office lack corridor walls that comply with 19.3.6.2.2.

7) The designated smoke barrier and corridor wall between the Reception Desk and the Therapist's Office has a plenum return air transfer opening in the wall above the ceiling. A smoke detector is installed in the opening; however no smoke detection is installed to comply with NFPA 90A and in accordance with 19.3.6.2.2.

8) Corrected 09/19/12

See also K67 and K104 - The scope of the deficiency cannot be cited under one tag. The correction of each needs to be coordinated with all of the deficiencies cited K017, K067 and K104, in order to fully correct each item.

Failure to maintain exit access corridors in accordance with NFPA 101 will result in migration of smoke throughout the building in a fire emergency.

Submittal as a project for any proposed corrective action will be required.

End

K020

A) Based on random observation, the surveyor finds that vertical openings are not installed and maintained in accordance with 19.3.1.1. Findings include:

1) Corrected 09/19/12
2) a) Corrected 09/19/12
b) Corrected 09/19/12
c) Corrected 09/19/12
3) a) Corrected 09/19/12
b) Corrected 09/19/12

4) There is a mechanical mezzanine above a 1st Floor Maintenance Space, between the Gym and the Kitchen. This "mezzanine" does not comply with NFPA 101, Section 8.2 and NFPA 90A:

a) The mezzanine does not meet the
requirements of a mezzanine. The space
is open to the 1st Floor hazardous area
below via a 3' x 8' floor opening with a
ships ladder. The floor opening is an
unprotected opening between two floors
and does not comply with 8.2.5 of NFPA
101.

b) The 1st Floor space below the
mezzanine is a hazardous area
that is not separated from the mechanical
(mezzanine) space above.

c) Corrected 09/19/12
5) Corrected 09/19/12

Submittal as a project for any proposed corrective action will be required.
Unprotected openings in vertical enclosures will allow heat and smoke to spread from floor to floor and will compromise that means of egress on multiple floors.

End

K028

A) Based upon random observation on multiple floors, the survey finds that single smoke doors in corridor walls and pair of cross corridor doors in designated smoke barriers have vision panels that are not wire glass or fire rated glazing. From observation the surveyor finds that many of the doors have vision panels that are plastic, laminated glass or tempered glass. Locations include but are not limited to:

1) Two of two Quiet Room, corridor doors in the designated smoke barrier of the East Wing, near the nurse's station.
UPDATES 09/19/12: One of the two corridor doors to Quiet Room was corrected on 09/19/12.

2) Corrected 09/19/12
3) Corrected 09/19/12
4) Corrected 09/19/12
5) Corrected 09/19/12
6) Corrected 09/19/12
7) Corrected 09/19/12

K029

A) Based on random observation the surveyor finds that hazardous areas are not enclosed in accordance with 19.3.2.1:

1) The Clean Utility Room in the 4th Floor Nurse's Station has a door with latching hardware that does not latch. The door lacks latching hardware that complies with NFPA 80.

2) The 4 West Storage Room, the 4th Floor Clean Utility Room (at the Nurse's Station) and the 4th Floor Soiled Utility Room (at the Nurse's Station) have unducted, plenum return air openings in the ceiling and the enclosure walls. Although some but not all plenum return air openings have smoke dampers, the smoke dampers are not installed and maintained to provide a smoke tight enclosure in accordance with 19.3.2.1.

3) Corrected 09/19/12

3) The 3 West Storage Room, the 3rd Floor Clean Utility Room (at the Nurse's Station) and the 3rd Floor Soiled Utility Room (at the Nurse's Station) have unducted, plenum return air openings in the ceiling and the enclosure walls. Although some but not all plenum return air openings have smoke dampers, the smoke dampers are not installed and maintained to provide a smoke tight enclosure in accordance with 19.3.2.1.

4) The 2 West Storage Room, the 2nd Floor Clean Utility Room (at the Nurse's Station) and the 2nd Floor Soiled Utility Room (at the Nurse's Station) have unducted, plenum return air openings in the ceiling and the enclosure walls. Although some but not all plenum return air openings have smoke dampers, the smoke dampers are not installed and maintained to provide a smoke tight enclosure in accordance with 19.3.2.1.

5) Corrected 09/19/12
6) Corrected 09/19/12


7) The 1st Floor Clean Linen Room Corridor door near the Kitchen is not self closing (closing device has been removed).

8) Corrected 09/19/12


9) All patient laundry rooms on all floors of the four story building are required to comply as hazardous area. These rooms are sprinklered but lack a smoke tight enclosure in accordance with NFPA 101 -19.3.1.1.

a) Corrected 09/19/12

b) The rooms have have a ducted system with a fire damper installed at the penetration into an adjacent shaft enclosure. The same duct also penetrates into adjacent rooms above the ceilings. Access above the ceilings in the adjacent rooms could not be provided - all adjacent rooms have monolithic ceilings. The surveyor is not able to confirm that this is not part of a plenum return air system that communicates to multiple floors and the exit access corridor

c. A combination fire/smoke damper is not installed at the shaft penetration with smoke detection installed in accordance with NFPA 72 and NFPA 90A.

d. The duct penetrations into adjacent rooms lack smoke dampers and smoke detection in accordance with NFPA 90A.

Failure to install and maintain smoke tight enclosures for hazardous areas could allow smoke to migrate to all patient areas and corridors during a fire emergency.

End

K067

A) Based on random observation the surveyor finds that mechanical (HVAC) systems, devices and materials are not installed in accordance with NFPA 90A - 1999.

1) Corrected 09/19/12
2) Corrected 09/19/12

3) The 1989 Building has two 5th Floor Mechanical Penthouses with an air handling unit in each. The East HVAC units is over 15,000 cfm and the system lacks smoke detection and combination smoke/ fire dampers installed at the return air penetration into the shaft on every floor, in accordance with Section 4-42 of NFPA 90A - 1999. HVAC system shut down and smoke detection on every floor is not provided. The surveyors observed smoke detection and dampers above the ceiling floor ceiling at the shaft but did not find them on the 1st Floor

Submittal as a project for any proposed corrective action will be required.

Failure to shut HVAC equipment down in accordance with NFPA 90A will result in smoke movement to multiple floors in a fire emergency.

End

K104

A) Based on random observation, personnel interview and document review the surveyor finds that although the 1989 building is fully sprinklered, it does not comply with the exception under 19.3.7.3. The entire building has a plenum return air system (unducted system) above ceilings. Smoke dampers at all penetrations though smoke barriers are required but are not provided in accordance with 8.3.5 of NFPA 101 -2000.

1) Although smoke dampers are installed in some but not all required locations the smoke dampers are not installed in accordance with 8.3.5 the dampers lack smoke detection in accordance with 8.3.5 and NFPA 72.

a) Locations where smoke dampers are installed but that lack smoke detection include but are not limited to the smoke barriers at the nurse's station wall at 2 East, 3 East and 4 East.

b) Locations where smoke dampers are not installed include but are not necessarily limited to 1st Floor Room 115.

c) In some locations, the surveyor observes that plenum return air openings have fire dampers installed where smoke dampers with smoke detection are required (see also K17). In some cases fire dampers were found where combination fire/smoke dampers may be required (see K104).

Failure to install and maintain smoke dampers in accordance with NFPA 101 and NFPA 90A will result in the migration of smoke to multiple locations on each floor in a fire emergency.

B) Vertical openings do not limit the travel of smoke from floor to floor to floor in accordance with 8.2 and 8.3 of NFPA 101: Locations include:

1) There is a duct shaft next to the exit stair on each floor (at the end of each wing). Each duct shaft communicates to a small 5th Floor Mechanical Penthouse. The supply and return air in each penthouse are fully ducted within the penthouse. The supply air duct in each shaft is fully ducted within the shaft and throughout each floor. Each supply air duct for these two systems has fire dampers where each duct penetrates the duct shaft.

However, the shaft enclosure from each 5th Floor penthouse is used as the return air duct (the supply air duct system is located inside of the return air duct. Two of two shafts have plenum return air openings on each floor with a fire damper installed at the opening into the shaft, above the ceiling on each floor. The fire dampers are not installed to resist the passage of smoke from floor to floor to floor (each smoke compartment on each floor communicates to every other floor via the plenum return air shafts).

Fire dampers and smoke dampers or combination fire/smoke dampers are not installed (with smoke detection at each plenum opening into each shaft) in accordance sections of NFPA 101 referenced.

The provider failed to provide any information that indicates that the above conditions are part of a smoke management or smoke control system.

Submittal as a project for any proposed corrective action will be required.

The lack of fire and smoke dampers for these shaft enclosures will allow smoke to pass from floor to floor to floor and will readily compromise all corridors and all rooms during a fire emergency.

End