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CHRISTUS MOTHER FRANCES HOSPITAL- JACKSONVILLE
Multiple Occupancies - Contiguous Non-Health
Tag No.: K0132
Based on observations made during the survey of the facility between the hours of 10:00 am and 2:00 pm, while accompanied by the Administrator, Director Business Services, and the Director Integrated Services it was observed that the facility was not in compliance regarding the following:
The LIFE SAFETY PLAN - Drawing Sheet "LS-1" (dated May 18, 2018) had been modified to remove the required 2 hour fire separation between the UNLICENSED CLINIC (Business Occupancy) and the LICENSED HOSPITAL's Main Entry Lobby & Admit Areas (also Business Occupancy) .
On-Site discussions, as well as looking above ceiling, and observing labeled rated door openings still in place - confirmed that the "ORIGINAL CONSTRUCTION" and the ORIGINAL CONSTRUCTION DRAWINGS had all considered the required 2 hour fire separation for which proper construction was still in place.
Since there were no modifications to the ORIGINAL CONSTRUCTION (2 hour fire separation) no further deficiencies were identified with regards to built environment's construction of the 2 hour separation.
The facility shall properly make drawing corrections to the LIFE SAFETY PLAN (RECORD DRAWINGS) to correctly show the required 2 hour fire separation between the UNLICENSED CLINIC (Business Occupancy) and the LICENSED HOSPITAL's Main Entry Lobby & Admit Areas (also Business Occupancy) .