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Based on random observation during the survey walk-through and staff interview, not all vertical openings are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. Duct penetrations through fire rated floor/ceiling assemblies for perimeter wall induction units were observed that are not equipped with fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.2. During an interview held on the Third Floor Med-Surg Unit on the morning of November 5, 2007, the facility's Director of Engineering stated that there approximately 85 such units in the building.

UPDATE 2/18/09: Although work has been performed on the above noted floor penetrations, it is not confirmed that compliance with applicable requirements is met. The following conditions were observed:

1. Corrected 10/23/09
2. Corrected 10/23/09

B. Corrected 07/22/08.
C. Corrected 07/22/08.

D. A duct penetration was observed, at a designated 2 hour fire rated shaft in the Fourth Floor North Mechanical Room, that is not equipped with a fire damper as required by 8.2.3.2.4.2. and NFPA 90A 1999 3-3.4.1.

UPDATE 10/23/09: The two hour rated wall is located between the SOMAT shaft and the mechanical rooms. The surveyor verified that E6 (toilet exhaust) and the AC#5 (air supply) failed to contain dampers where they penetrate the two hour rated separation wall between the mechanical room and the shaft wall.
The facility indicated that the two mechanical rooms are part of the shaft and therefore would not require dampers at the wall penetration between the mechanical rooms and the SOMAT shaft.

The surveyor was informed that the mechanical rooms are part of the shaft enclosure and do not contain fuel fired equipment or storage.

UPDATE 6/23/10: The surveyor finds that the above deficiency was not corrected in accordance with the last submitted PoC. The provider failed to install fire dampers in accordance with the PoC.

Alternately, the provider failed to modify the PoC and to remove and maintain this 4th Floor Mechanical Room free of storage. On 6/23/10 the room was found with metal storage cabinets, a flammable liquids cabinet, a desk, contractor carts and materials, an oxy-acetylene torch, two unsecured acetylene tanks and a number of cardboard boxes.

E. (New 6/23/10): There is an abandoned generator floor in a corner of the 4th Floor Mechanical Room. This flue is not isolated from this mechanical room and other mechanical rooms below by a fire rated shaft enclosure. Further, the 4th Floor Mechanical Room is open to the floor below at the location where the flue penetrates the 4th Floor.

F. (New 6/23/10): A new 2" electrical conduit penetrates the 4th Floor Mechanical Room floor and the floors of the spaces below. These penetrations through the two hour floor assemblies are not sealed (temporarily or permanently) by two hour construction.

G. (New 6/23/10): According to statements made by the provider, they have information that indicates that vertical shafts lack fire dampers at multiple floors and do not comply with NFPA 90A. Further, fire dampers at some locations are not installed in the plane of the fire barriers. The surveyor finds that this information relates directly to deficiencies already cited under K020 and K067. The provider failed to revised the PoC to reflect correction of all such deficiencies.

H. See also K067

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A.

Findings include:

A. Ventilating shafts were observed that contain combustible storage as prohibited by NFPA 90A 1999 3-3.4.3.(7). Locations and materials observed include:

1. Corrected 07/22/08.
2. Corrected 07/22/08.
3. Corrected 07/22/08.
4. Corrected 07/22/08.

5. Ground Floor Mechanical Room which communicates with SOMAT Shaft.

UPDATE 2/18/09: The citation from this
update was uncorrected as 06/23/10:

*The Ground Floor Mechanical Room
remains unseparated from the SOMAT
shaft.

*The Ground Floor Mechanical Room is
still be used for storage, including
combustible storage.

UPDATE 10/23/09: The citation at the 1st
Floor Imaging Reading Room appears to be
corrected as of 06/23/10.

UPDATE and modified 06/23/10: The
citation remains uncorrected and was not
corrected in accordance with the last
submitted PoC - see below:

B) 6/23/10: The Ground Floor Mechanical Room identified in item "A- 5" above does not comply with NFPA 90A:

1) The room has duct penetrations with fire dampers were ducts penetrate walls and some duct penetrations have fire dampers at duct penetrations into the shafts or floors above. Some ducts penetrate the walls without fire dampers and every duct that penetrates a shaft or floor above does not have a fire damper. The provider's lacks a comprehensive fire damper schedule. Many fire damper are not labeled as fire dampers and lack unique identification for each damper on the damper access panel.

The provider is not able to demonstrate how this mechanical room complies with NFPA 90A as a room that is separated from vertical shafts or as a room that is part of the vertical shafts above. on 6/23/10, the room was still being used for storage of combustibles.

2) The Ground Floor Mechanical Room has an abandoned SOMAT Chute that has been capped off in the Mechanical Room. The provider is not able to demonstrate how this chute and the vertical shaft that contains it is separated from the Mechanical Room by two hour fire rated construction.

3) New shaft construction was created at one end of the mechanical room to separate the room from the SOMAT shaft above. This construction is incomplete:

a) The fire rated access panel is not self
closing (springs to keep access panel
shut are not properly adjusted). The
access panel is not installed in the
ceiling plane (horz shaft wall) with
drywall framing the opening behind the
frame (it is not installed in accordance
with MFR requirements)

b) The horizontal shaft wall is supported by
steel "c" joist above that are not
protected as two hour fire rated
construction. The vertical walls of this
shaft separation also have unprotected
steel studs inside the shaft.

c) A round duct penetrates this shaft wall
construction and lacks a fire damper.

C) (New 6/23/10): Ground Floor Mech Rm: The access door for the air intake for AC-1 was found to be open with the outside air intake by-passed by this condition.

D) See also K020

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.

B. Data cables and other utilities were observed throughout the building that are supported by other utilities as prohibited by the codes cited below. Surveyor 14290 notes that this condition was observed to be pervasive throughout the facility.

1. Data cables and other utilities supported by sprinkler piping, prohibited by NFPA 13 1999 6-1.1.5.

2. Data cables and other utilities supported by ductwork, prohibited by NFPA 90A 1999 2-3.1.4.

3. Data cables and other utilities supported by medical gas piping, prohibited by NFPA 99 1999 4-3.1.2.9(c).

4. Data cables and other utilities supported by electrical conduit, prohibited by NFPA 70 1999 300-11(b).

C. Corrected 07/22/08.

UPDATE 10/23/09: Deleted 6/23/10

UPDATE 06/23/10: The provider has a written investigative report that identifies which areas must be corrected and it identifies priorities. This report is incorrectly associated with a request for a waiver. The corrective actions proposed in this report have not been specifically identified in the PoC and/or they have not been referenced by letter and date in the PoC (and this document has not been attached to the PoC).

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

1. Corrected 2/18/09.
2. Corrected 07/22/08.
3. Corrected 07/22/08.
4. Corrected 6/23/10

5. GENERAL ITEM - . Emergency power devices do not comply with NFPA 70-700-9(a). NFPA 70-700-9(a) requires that all boxes & enclosures (ATS & power panels) for emergency circuits shall be permanently marked as to be readily identified as emergency system(s). The marking may be a color code, the identification "emergency system," or any other type of identification that will identify the box or enclosure as a component of the emergency system. Indicate which branch of emergency system, e.g. - Life Safety - Critical - Equipment.

6/23/10: The above item was not corrected in accordance with the last submitted PoC.

6. 3rd Floor, Med Prep Room #C3010, the lighting and selected duplex receptacles are not connected to critical power as required by NFPA 70-517-33.

6/23/10: The above item was not corrected in accordance with the last submitted PoC.

7. 3rd Floor corridor electrical panel #PM 3362-3 (life safety) has connected loads that are not allowed per NFPA 70-517-32.

6/23/10: The above item was not corrected in accordance with the last submitted PoC.

8. 2nd Floor, of 67 Building, Post OB Area patient rooms do not have red emergency duplex receptacles as required by NFPA 70-517.

UPDATE 10/23/09: the coverplate was red but not the receptacle. Emergency receptacle(s) shall be identified and shall be labeled with the panelboard and circuit number suppling the device in accordance with NFPA 70. 6/23/10 - the requirement for red faceplates is not specfically required; however, the facilities standard for identifying emergency outlets appears to be red outlets with red face-plates (based upon random observation). The locatoins cited were not consistant with the facilities standards.

6/23/10: The above item was not corrected in accordance with the last submitted PoC

9. Corrected 07/22/08.
10. Corrected 07/22/08.
11. Corrected 07/22/08.
12. Corrected 2/18/09.
13. Corrected 2/18/09.
14. Corrected 07/22/08.
15. Corrected 07/22/08.

Based on random observation during the survey walk-through and staff interview, not all vertical openings are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. Duct penetrations through fire rated floor/ceiling assemblies for perimeter wall induction units were observed that are not equipped with fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.2. During an interview held on the Third Floor Med-Surg Unit on the morning of November 5, 2007, the facility's Director of Engineering stated that there approximately 85 such units in the building.

UPDATE 2/18/09: Although work has been performed on the above noted floor penetrations, it is not confirmed that compliance with applicable requirements is met. The following conditions were observed:

1. Corrected 10/23/09
2. Corrected 10/23/09

B. Corrected 07/22/08.
C. Corrected 07/22/08.

D. A duct penetration was observed, at a designated 2 hour fire rated shaft in the Fourth Floor North Mechanical Room, that is not equipped with a fire damper as required by 8.2.3.2.4.2. and NFPA 90A 1999 3-3.4.1.

UPDATE 10/23/09: The two hour rated wall is located between the SOMAT shaft and the mechanical rooms. The surveyor verified that E6 (toilet exhaust) and the AC#5 (air supply) failed to contain dampers where they penetrate the two hour rated separation wall between the mechanical room and the shaft wall.
The facility indicated that the two mechanical rooms are part of the shaft and therefore would not require dampers at the wall penetration between the mechanical rooms and the SOMAT shaft.

The surveyor was informed that the mechanical rooms are part of the shaft enclosure and do not contain fuel fired equipment or storage.

UPDATE 6/23/10: The surveyor finds that the above deficiency was not corrected in accordance with the last submitted PoC. The provider failed to install fire dampers in accordance with the PoC.

Alternately, the provider failed to modify the PoC and to remove and maintain this 4th Floor Mechanical Room free of storage. On 6/23/10 the room was found with metal storage cabinets, a flammable liquids cabinet, a desk, contractor carts and materials, an oxy-acetylene torch, two unsecured acetylene tanks and a number of cardboard boxes.

E. (New 6/23/10): There is an abandoned generator floor in a corner of the 4th Floor Mechanical Room. This flue is not isolated from this mechanical room and other mechanical rooms below by a fire rated shaft enclosure. Further, the 4th Floor Mechanical Room is open to the floor below at the location where the flue penetrates the 4th Floor.

F. (New 6/23/10): A new 2" electrical conduit penetrates the 4th Floor Mechanical Room floor and the floors of the spaces below. These penetrations through the two hour floor assemblies are not sealed (temporarily or permanently) by two hour construction.

G. (New 6/23/10): According to statements made by the provider, they have information that indicates that vertical shafts lack fire dampers at multiple floors and do not comply with NFPA 90A. Further, fire dampers at some locations are not installed in the plane of the fire barriers. The surveyor finds that this information relates directly to deficiencies already cited under K020 and K067. The provider failed to revised the PoC to reflect correction of all such deficiencies.

H. See also K067

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A.

Findings include:

A. Ventilating shafts were observed that contain combustible storage as prohibited by NFPA 90A 1999 3-3.4.3.(7). Locations and materials observed include:

1. Corrected 07/22/08.
2. Corrected 07/22/08.
3. Corrected 07/22/08.
4. Corrected 07/22/08.

5. Ground Floor Mechanical Room which communicates with SOMAT Shaft.

UPDATE 2/18/09: The citation from this
update was uncorrected as 06/23/10:

*The Ground Floor Mechanical Room
remains unseparated from the SOMAT
shaft.

*The Ground Floor Mechanical Room is
still be used for storage, including
combustible storage.

UPDATE 10/23/09: The citation at the 1st
Floor Imaging Reading Room appears to be
corrected as of 06/23/10.

UPDATE and modified 06/23/10: The
citation remains uncorrected and was not
corrected in accordance with the last
submitted PoC - see below:

B) 6/23/10: The Ground Floor Mechanical Room identified in item "A- 5" above does not comply with NFPA 90A:

1) The room has duct penetrations with fire dampers were ducts penetrate walls and some duct penetrations have fire dampers at duct penetrations into the shafts or floors above. Some ducts penetrate the walls without fire dampers and every duct that penetrates a shaft or floor above does not have a fire damper. The provider's lacks a comprehensive fire damper schedule. Many fire damper are not labeled as fire dampers and lack unique identification for each damper on the damper access panel.

The provider is not able to demonstrate how this mechanical room complies with NFPA 90A as a room that is separated from vertical shafts or as a room that is part of the vertical shafts above. on 6/23/10, the room was still being used for storage of combustibles.

2) The Ground Floor Mechanical Room has an abandoned SOMAT Chute that has been capped off in the Mechanical Room. The provider is not able to demonstrate how this chute and the vertical shaft that contains it is separated from the Mechanical Room by two hour fire rated construction.

3) New shaft construction was created at one end of the mechanical room to separate the room from the SOMAT shaft above. This construction is incomplete:

a) The fire rated access panel is not self
closing (springs to keep access panel
shut are not properly adjusted). The
access panel is not installed in the
ceiling plane (horz shaft wall) with
drywall framing the opening behind the
frame (it is not installed in accordance
with MFR requirements)

b) The horizontal shaft wall is supported by
steel "c" joist above that are not
protected as two hour fire rated
construction. The vertical walls of this
shaft separation also have unprotected
steel studs inside the shaft.

c) A round duct penetrates this shaft wall
construction and lacks a fire damper.

C) (New 6/23/10): Ground Floor Mech Rm: The access door for the air intake for AC-1 was found to be open with the outside air intake by-passed by this condition.

D) See also K020

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.

B. Data cables and other utilities were observed throughout the building that are supported by other utilities as prohibited by the codes cited below. Surveyor 14290 notes that this condition was observed to be pervasive throughout the facility.

1. Data cables and other utilities supported by sprinkler piping, prohibited by NFPA 13 1999 6-1.1.5.

2. Data cables and other utilities supported by ductwork, prohibited by NFPA 90A 1999 2-3.1.4.

3. Data cables and other utilities supported by medical gas piping, prohibited by NFPA 99 1999 4-3.1.2.9(c).

4. Data cables and other utilities supported by electrical conduit, prohibited by NFPA 70 1999 300-11(b).

C. Corrected 07/22/08.

UPDATE 10/23/09: Deleted 6/23/10

UPDATE 06/23/10: The provider has a written investigative report that identifies which areas must be corrected and it identifies priorities. This report is incorrectly associated with a request for a waiver. The corrective actions proposed in this report have not been specifically identified in the PoC and/or they have not been referenced by letter and date in the PoC (and this document has not been attached to the PoC).

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

1. Corrected 2/18/09.
2. Corrected 07/22/08.
3. Corrected 07/22/08.
4. Corrected 6/23/10

5. GENERAL ITEM - . Emergency power devices do not comply with NFPA 70-700-9(a). NFPA 70-700-9(a) requires that all boxes & enclosures (ATS & power panels) for emergency circuits shall be permanently marked as to be readily identified as emergency system(s). The marking may be a color code, the identification "emergency system," or any other type of identification that will identify the box or enclosure as a component of the emergency system. Indicate which branch of emergency system, e.g. - Life Safety - Critical - Equipment.

6/23/10: The above item was not corrected in accordance with the last submitted PoC.

6. 3rd Floor, Med Prep Room #C3010, the lighting and selected duplex receptacles are not connected to critical power as required by NFPA 70-517-33.

6/23/10: The above item was not corrected in accordance with the last submitted PoC.

7. 3rd Floor corridor electrical panel #PM 3362-3 (life safety) has connected loads that are not allowed per NFPA 70-517-32.

6/23/10: The above item was not corrected in accordance with the last submitted PoC.

8. 2nd Floor, of 67 Building, Post OB Area patient rooms do not have red emergency duplex receptacles as required by NFPA 70-517.

UPDATE 10/23/09: the coverplate was red but not the receptacle. Emergency receptacle(s) shall be identified and shall be labeled with the panelboard and circuit number suppling the device in accordance with NFPA 70. 6/23/10 - the requirement for red faceplates is not specfically required; however, the facilities standard for identifying emergency outlets appears to be red outlets with red face-plates (based upon random observation). The locatoins cited were not consistant with the facilities standards.

6/23/10: The above item was not corrected in accordance with the last submitted PoC

9. Corrected 07/22/08.
10. Corrected 07/22/08.
11. Corrected 07/22/08.
12. Corrected 2/18/09.
13. Corrected 2/18/09.
14. Corrected 07/22/08.
15. Corrected 07/22/08.