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While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011, it was observed that the facility was not compliant with this regulation because a suitable means to keep the corridor doors closed was not provided.

Findings include:
Item #1: It was observed at 2:48pm on Monday (November 14th) that no positive latching was provided for the exit access door into the corridor from the Respitory Therapist office (First floor). A roller latch secured this door.
Item #2: It was observed at 2:52pm on Monday (November 14th) that no positive latching was provided for the exit access door into the corridor from the Pharmacology (First floor). A roller latch secured this door.
Item #3: It was observed at 2:57pm on Monday (November 14th) that no positive latching was provided for the exit access door into the corridor from the Dirty Linen Holding (First floor). A roller latch secured this door.
Item #4: It was observed at 2:57pm on Monday (November 14th) that no positive latching was provided for the exit access door into the corridor from the Dirty Linen Holding (First floor). A roller latch secured this door.
Item #5: It was observed at 8:09am on Tuesday (November 15th) that no positive latching was provided for the exit access door into the corridor from the Emergency Prep Room (First floor). A roller latch secured this door
Item #6: It was observed at 9:15am on Tuesday (November 15th) that no positive latching was provided for the west exit access door into the corridor from the Kitchen (Basement floor). A roller latch secured this door
Item #7: It was observed at 9:20am on Tuesday (November 15th) that no positive latching was provided for the exit access doors into the corridor from 12+ rooms on the Third floor. Roller latches secured these doors.
Item #8: It was observed at 9:15am on Tuesday (November 15th) that no positive latching was provided for the two exit access doors into the corridor from the Kitchen and Dishwashing rooms (Basement level). Neither door had a latching mechanism only deadbolts.
Item #9: The doors into the Substerile ante room of Surgery and into the ED Exam room were not provided with positive latching for these exit access doors into the corridor.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011, it was observed that the facility was not compliant with this regulation because the basic components to separate a hazardous area from the remainder of the building was not provided, as evidenced by the following items.

Item #1: It was observed at 1:40pm on Monday (November 14th) that a storage area located off the admissions office was greater than 50 square feet and not provided with a 45-minute rated door and a closer to properly separate this hazardous area.
Item #2: It was observed at 1:50pm on Monday (November 14th) that the X-ray records office was greater than 50 square feet and not provided with a 45-minute rated door and a closer, to properly separate this hazardous area.
Item #3: It was observed at 2:41pm on Monday (November 14th) that the hazardous enclosure around the lab was not complete.
(a) the 90-minute door was not equipped with a door closer
(b) there were 4 pipe penetrations and one duct that were not caulked to a two-hour rating.
Item #4: It was observed at 2:57pm on Monday (November 14th) that the hazardous enclosure around Dirty Linen Holding was not complete.
(a) the door was not equipped with a door closer
(b) the door was not rated no label was present on the leaf.
Item #5:: It was observed at 8:09am on Tuesday (November 15th) that the Womens' locker room was being shared with the Emergency Preparednes Room. The locker room is greater than 50 square feet the two areas are open to each other. Substantial amounts of combustible storage are being kept in this common space.
(a) the door is not positive latching
(b) no rating is provided for the leaf
(c) no door closer is installed.
Item #6: It was observed at 8:36am on Tuesday (November 15th) that the hazardous enclosure around Boiler room was not complete.
(a) two metal pipes in the east wall were not fire caulked to the two-hour standard for this room.
Item #7: It was observed at 8:38am on Tuesday (November 15th) that the hazardous enclosure around Medical Records storage was not complete.
(a) two metal pipes in the east wall were not fire caulked to the one-hour standard for this room.
Item #8: It was observed at 8:39am on Tuesday (November 15th) that the hazardous enclosure around the Elevator Equipment room was not complete.
(a) no door closer was installed on this door.
Item #9: It was observed at 8:48am on Tuesday (November 15th) that the hazardous enclosure around the HVAC room was not complete.
(a) three copper pipes in the east wall were not fire caulked to the two-hour standard for this room.
Item #10: It was observed at 8:52am on Tuesday (November 15th) that the hazardous enclosure around Laundry room was not complete.
(a) 10+ pipe penetrations in the walls and floor deck were not fire caulked to a one-hour standard for this room.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011, the stairways are required to meet Section 7.2. It was observed that the facility was not compliant with this regulation that as evidenced by the following items.

Findings include:

Item #1: It was observed at 1:48pm on Tuesday (November 14th) that the landing from the southwest stair leading to the front of the hospital did not have an exterior landing that was level with the interior landing as required by 7.2.1.3.
Item #2: It was observed at 1:49pm on Tuesday (November 14th) that the risers from this stair on the exterior of the building were not uniform in height as required in 7.2.2.3.5.
Item #3: It was observed at 1:52pm on Tuesday (November 14th) that the landing from the northeast stair leading to the back of the hospital did not have an exterior landing that was level with the interior landing as required by 7.2.1.3.
Item #4: It was observed at 1:53pm on Tuesday (November 14th) that the risers from this northeast stair on the exterior of the building were not uniform in height as required in 7.2.2.3.5.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011 it was observed that the facility was not compliant with this regulation for the fire alarm system as evidenced by the following items.

Findings include:

Item #1: During document review on Tuesday (November 15) at 3:15pm, it was verified during an interview with Staff T, that the Fire Alarm panel was unserviceable by the technicians from the service company that maintained this panel on an annual basis. The employees that service this panel did not have knowledge of how to fix any problem with this equipment. It was noted in the interview that the service technicians who could service this equipment had retired.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011, it was observed that the HVAC system for the facility was not compliant with this regulation as evidenced by the following item.

Findings include:

It was observed at 1:38pm on Tuesday (November 15th) that the door from the substerile ante room into the soiled decontamination room for initial scope cleaning had been removed. The door allowed a positive movement from this substerile area into the decontamination room which is continually exhausted. Without the door, air flows are not maintained as designed.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011; it was observed that Medical gas storage was not compliant with this regulation as evidenced by the following item.

Findings include:

It was observed at 1:03pm on Monday (November 14th) that the Oxygen tanks and other medical gas cylinders were being stored in the Oxygen storage room. In addition to these items, all hospital biohazards were being kept in this same space with red 32 gallon plastic drums as well as the soiled linen cart, awaiting pick up from the service contractors for these two materials.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011; it was observed that the facility was not compliant with this regulation as evidenced by the following item.

Findings include:

It was observed at 2:35pm on Tuesday (November 15th) that the Bulk Oxygen tank storage area was not provided with a concrete pad to protect against spillage during the filling of this tank. NFPA 99 Section 8-6.2.2.3 states; "Flammable and combustible liquids shall not be permitted within the site of intentional expulsion." The material being used was an asphalt surface. The slope of this asphalt did not meet the maximum slope allowed for the area around the hose connection.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011; it was observed that the facility was not compliant with this regulation as evidenced by the following items.

Findings include:

Item #1: It was observed at 1:44pm on Monday (November 14th) that a soiled ceiling tile was present in the Admissions office in the southeast corner.(First Floor)
Item #2: It was observed at 2:55pm on Monday (November 14th) that a soiled ceiling tile was present in the CT exam room.(First Floor)
Item #3: It was observed at 2:48pm on Monday (November 14th) that a soiled ceiling tile was present in the Respiratory therapist office.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011, it was observed that the facility was not compliant with this regulation because a suitable means to keep the corridor doors closed was not provided.

Findings include:
Item #1: It was observed at 2:48pm on Monday (November 14th) that no positive latching was provided for the exit access door into the corridor from the Respitory Therapist office (First floor). A roller latch secured this door.
Item #2: It was observed at 2:52pm on Monday (November 14th) that no positive latching was provided for the exit access door into the corridor from the Pharmacology (First floor). A roller latch secured this door.
Item #3: It was observed at 2:57pm on Monday (November 14th) that no positive latching was provided for the exit access door into the corridor from the Dirty Linen Holding (First floor). A roller latch secured this door.
Item #4: It was observed at 2:57pm on Monday (November 14th) that no positive latching was provided for the exit access door into the corridor from the Dirty Linen Holding (First floor). A roller latch secured this door.
Item #5: It was observed at 8:09am on Tuesday (November 15th) that no positive latching was provided for the exit access door into the corridor from the Emergency Prep Room (First floor). A roller latch secured this door
Item #6: It was observed at 9:15am on Tuesday (November 15th) that no positive latching was provided for the west exit access door into the corridor from the Kitchen (Basement floor). A roller latch secured this door
Item #7: It was observed at 9:20am on Tuesday (November 15th) that no positive latching was provided for the exit access doors into the corridor from 12+ rooms on the Third floor. Roller latches secured these doors.
Item #8: It was observed at 9:15am on Tuesday (November 15th) that no positive latching was provided for the two exit access doors into the corridor from the Kitchen and Dishwashing rooms (Basement level). Neither door had a latching mechanism only deadbolts.
Item #9: The doors into the Substerile ante room of Surgery and into the ED Exam room were not provided with positive latching for these exit access doors into the corridor.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011, it was observed that the facility was not compliant with this regulation because the basic components to separate a hazardous area from the remainder of the building was not provided, as evidenced by the following items.

Item #1: It was observed at 1:40pm on Monday (November 14th) that a storage area located off the admissions office was greater than 50 square feet and not provided with a 45-minute rated door and a closer to properly separate this hazardous area.
Item #2: It was observed at 1:50pm on Monday (November 14th) that the X-ray records office was greater than 50 square feet and not provided with a 45-minute rated door and a closer, to properly separate this hazardous area.
Item #3: It was observed at 2:41pm on Monday (November 14th) that the hazardous enclosure around the lab was not complete.
(a) the 90-minute door was not equipped with a door closer
(b) there were 4 pipe penetrations and one duct that were not caulked to a two-hour rating.
Item #4: It was observed at 2:57pm on Monday (November 14th) that the hazardous enclosure around Dirty Linen Holding was not complete.
(a) the door was not equipped with a door closer
(b) the door was not rated no label was present on the leaf.
Item #5:: It was observed at 8:09am on Tuesday (November 15th) that the Womens' locker room was being shared with the Emergency Preparednes Room. The locker room is greater than 50 square feet the two areas are open to each other. Substantial amounts of combustible storage are being kept in this common space.
(a) the door is not positive latching
(b) no rating is provided for the leaf
(c) no door closer is installed.
Item #6: It was observed at 8:36am on Tuesday (November 15th) that the hazardous enclosure around Boiler room was not complete.
(a) two metal pipes in the east wall were not fire caulked to the two-hour standard for this room.
Item #7: It was observed at 8:38am on Tuesday (November 15th) that the hazardous enclosure around Medical Records storage was not complete.
(a) two metal pipes in the east wall were not fire caulked to the one-hour standard for this room.
Item #8: It was observed at 8:39am on Tuesday (November 15th) that the hazardous enclosure around the Elevator Equipment room was not complete.
(a) no door closer was installed on this door.
Item #9: It was observed at 8:48am on Tuesday (November 15th) that the hazardous enclosure around the HVAC room was not complete.
(a) three copper pipes in the east wall were not fire caulked to the two-hour standard for this room.
Item #10: It was observed at 8:52am on Tuesday (November 15th) that the hazardous enclosure around Laundry room was not complete.
(a) 10+ pipe penetrations in the walls and floor deck were not fire caulked to a one-hour standard for this room.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011, the stairways are required to meet Section 7.2. It was observed that the facility was not compliant with this regulation that as evidenced by the following items.

Findings include:

Item #1: It was observed at 1:48pm on Tuesday (November 14th) that the landing from the southwest stair leading to the front of the hospital did not have an exterior landing that was level with the interior landing as required by 7.2.1.3.
Item #2: It was observed at 1:49pm on Tuesday (November 14th) that the risers from this stair on the exterior of the building were not uniform in height as required in 7.2.2.3.5.
Item #3: It was observed at 1:52pm on Tuesday (November 14th) that the landing from the northeast stair leading to the back of the hospital did not have an exterior landing that was level with the interior landing as required by 7.2.1.3.
Item #4: It was observed at 1:53pm on Tuesday (November 14th) that the risers from this northeast stair on the exterior of the building were not uniform in height as required in 7.2.2.3.5.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011 it was observed that the facility was not compliant with this regulation for the fire alarm system as evidenced by the following items.

Findings include:

Item #1: During document review on Tuesday (November 15) at 3:15pm, it was verified during an interview with Staff T, that the Fire Alarm panel was unserviceable by the technicians from the service company that maintained this panel on an annual basis. The employees that service this panel did not have knowledge of how to fix any problem with this equipment. It was noted in the interview that the service technicians who could service this equipment had retired.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011, it was observed that the HVAC system for the facility was not compliant with this regulation as evidenced by the following item.

Findings include:

It was observed at 1:38pm on Tuesday (November 15th) that the door from the substerile ante room into the soiled decontamination room for initial scope cleaning had been removed. The door allowed a positive movement from this substerile area into the decontamination room which is continually exhausted. Without the door, air flows are not maintained as designed.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011; it was observed that Medical gas storage was not compliant with this regulation as evidenced by the following item.

Findings include:

It was observed at 1:03pm on Monday (November 14th) that the Oxygen tanks and other medical gas cylinders were being stored in the Oxygen storage room. In addition to these items, all hospital biohazards were being kept in this same space with red 32 gallon plastic drums as well as the soiled linen cart, awaiting pick up from the service contractors for these two materials.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011; it was observed that the facility was not compliant with this regulation as evidenced by the following item.

Findings include:

It was observed at 2:35pm on Tuesday (November 15th) that the Bulk Oxygen tank storage area was not provided with a concrete pad to protect against spillage during the filling of this tank. NFPA 99 Section 8-6.2.2.3 states; "Flammable and combustible liquids shall not be permitted within the site of intentional expulsion." The material being used was an asphalt surface. The slope of this asphalt did not meet the maximum slope allowed for the area around the hose connection.

While on tour of the facility with the Maintenance Director between November 14th and 16th, 2011; it was observed that the facility was not compliant with this regulation as evidenced by the following items.

Findings include:

Item #1: It was observed at 1:44pm on Monday (November 14th) that a soiled ceiling tile was present in the Admissions office in the southeast corner.(First Floor)
Item #2: It was observed at 2:55pm on Monday (November 14th) that a soiled ceiling tile was present in the CT exam room.(First Floor)
Item #3: It was observed at 2:48pm on Monday (November 14th) that a soiled ceiling tile was present in the Respiratory therapist office.