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Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. This deficiency could affect any patients, staff, or visitors in that portion of the building because the building structure in that area could fail under fire conditions more quickly than in other parts of the building.

Findings include:

A. At 2:12 PM on May 29, 2012, unprotected steel beams and open web steel joists were observed above the ceiling in the Fourth Floor B Wing. During an interview held at that time and location, the provider's Manager of Architectural Services confirmed that, in a number of areas in the Fourth Floor B Wing, the drywall membrane that had been originally installed on the underside of the open web steel joists to complete the UL Design for the fire rated roof/ceiling assembly had been subsequently removed.

Update 01/29/13: An FSES was submitted for Item A. The Department reviewed and accepted the FSES documents.

NOTE 11/07/13: During the survey walk-through, it was observed thaqt the fireproofing of the structural steel was in process.



16339


A. 1.Corrected 01/29/13.

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. This deficiency could affect any patients, staff, or visitors in the smoke compartment housing the Servery because smoke could be permitted to enter the adjacent corridor.

Findings include:

A. At 10:30 AM on May 31, 2012, the First Floor Cafeteria Servery, which includes commercial cooking equipment including a grill and a kitchen hood suppression system, was observed to not be separated from the adjacent Corridor because the east wall and door of the Servery are not resistant to the passage of smoke, as required by 19.3.2.1., because they include glass panes with gaps between them and a chain link gate.

NOTE 11/07/13: During the survey walk-through it was observed that the corrective action, including the installation of a Won-Door, was in process.

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16339


A. 1. Corrected 01/29/13.

Based on random observation during the survey walk-through and document review, not all designated suites are provided with exits in accordance with 19.2.5.2. This deficiency could affect any patients, visitors, or staff in the suite because access to a corridor will require a longer travel distance than in a suite of complaint size.

Findings include:

A. At 10:57 AM on May 30, 2012, the Second Floor NICU Suite was observed to be in excess of 5,000 square feet in area as prohibited by 19.2.5.6. The Rated Wall Master Plan for the facility, dated April 20, 2012, identifies the area of the suite as 8,878 square feet.

Update 01/29/13: An FSES was submitted for Item A. The Department reviewed and accepted the FSES documents.

NOTE 11/07/13: During the survey walk-through, it was noted that a pair of doors in the designated suite barrier wall is not positive latching as required by 19.3.6.3.2.

A. Corrected 01/29/13.


17659


Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

1. Corrected 01/29/13.
2. Corrected 01/29/13.

3. The transfer switch for the fire pump is not located at the pump location as required by NFPA 20-6-6.4.


26665


A. Corrected 01/29/13.

Based on random observationduring the survey walk-through the generator equipment does not meet all requirements of NFPA-110.

Findings include:

1. The generators were located in the same room as the 12470 Volt primary power service equipment which does not comply with NFPA-110, Section 5-2.1. This deficiencies could affect all building occupants because a failure of the generators could also effect the normal power service.

2. Corrected 01/29/13.

3. Corrected 01/29/13.

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.

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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:

1. Life Safety, Critical and Equipments branches of power were not separated throughout the building. The E-wing of the building had no separation at all, all branches were served by a single transfer switch. Areas of the building where modernization projects had been performed had some separation , but there were still emergency panels throughout that had mixtures of critical and equipment such as panel LPEMA4 and EMB4 which served patient rooms but also served room heating and cooling equipment, and panels such as LPEM4, EMB3, LPEMA3, EC3, ELS, LPEMA2, and 2CLR2 which were serving critical and life safety loads. The loads served by the emergency power system should be separated into three branches to comply with NFPA-70, Sections 517-32 through 34, and NFPA-99, Section 3-4.2.2.2 and 3-4.2.2.3.

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