HospitalInspections.org

Based on observations and confirmed by staff, the facility failed to maintain corridor doors to: - resist the passage of smoke,
- ensure that there are no impediments to the closing of doors protecting corridor openings ( NOTE: Hold-open devices that release when the door is pushed or pulled - no manual unlatching or releasing action necessary to close) are permitted, such as friction catches or magnetic catches, and
- ensure that corridor doors close completely and latch tightly in their frames.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/11/13 revealed the following the first floor corridor door to Room #5 was not smoke tight due to three (3), one half inch ( ? " ) diameter holes located around the door knob.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to maintain corridor doors to: - resist the passage of smoke,
- ensure that there are no impediments to the closing of doors protecting corridor openings ( NOTE: Hold-open devices that release when the door is pushed or pulled - no manual unlatching or releasing action necessary to close) are permitted, such as friction catches or magnetic catches, and
- ensure that corridor doors close completely and latch tightly in their frames.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/10/13 revealed the following:

1. Three (3), one half inch ( ? " ) diameter holes are located in the second floor corridor door labeled #2-02- 401 (Managers office).

2. Door wedges are utilized on the second floor corridor doors labeled #2-01-401 and #2-01-402.

3. The corridor doors to the Staff Lounge 4-01-300 on the fourth floor and the Staff Lounge 2-06-403 on the second floor were equipped with magnetic devices to keep the doors closed. However, these devices release upon activation of the fire alarm. Therefore, the corridor doors to these rooms are not provided with a means for keeping the door closed in accordance with Section 19-3.6.3.2.

4. The corridor doors to Room #'s 4-02-213 and 4-02-207 on the fourth floor did not latch in their frames.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier walls are properly maintained.

THE FINDINGS INCLUDE:

During the morning hours of 12/11/13 while touring the facility, it was observed that smoke barrier walls in the following areas have unsealed penetrations:

1. 1st floor - Above the double doors, # 1-11-000, that lead into the Emergency Department, there are two, 2- inch conduits not sealed and two, 2-inch holes in the wall.

2. 1st floor - Above the door that leads into the MRI area , there is 2 foot by 3 foot hole in the wall.

3. 1st floor - Various voids in the smoke barrier wall by doors #1-01-001.

4. 3rd floor - Two voids in the smoke barrier to the CUICU above doors #3-10-000 which were not sealed.

5. 3rd floor - Three voids in the smoke barrier wall above smoke barrier doors #3-13-000.

6. 4th floor - Voids around the pipe penetrations in the corridor wall above door #4-02-801.

These voids should be sealed to provide at least a one half hour fire resistance rating in accordance with 8.3.


This was acknowledged by facility personnel during the tour an by Administration and the Director of Engineering during the exit interview process.

Based on observations, plan review, and confirmed by staff, the facility failed to provide smoke barrier walls with a 1-hour fire rating assembly.

THE FINDINGS INCLUDE:

During the morning hours of 12/11/13 while touring the facility, it was observed that the smoke barrier walls located in the following areas had voids:

1) 5th floor - Above the center core door there were 5 data lines not sealed.

2) 5th floor - Above the cross corridor door located near room 513, a void is located behind the 2 inch sprinkler pipe.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier doors are maintained in the proper operating condition and in compliance with Section 18.3.7.8.

THE FINDINGS INCLUDE:

During the morning hours of 12/11/13 while touring the facility, it was observed that the smoke barrier doors would not close tight.

1) 6th floor center core - The latching device prevents the smoke barrier door from closing tight.

2) 5th floor center core - The smoke barrier door is rubbing against the door frame preventing the door from closing tight.

3) 4th floor cross corridor - The smoke barrier door near room 413 is rubbing against the frame preventing the door from closing tight.

4) The smoke barrier doors, identified as 3-32-002, have a gap greater than 1/8 inch. These doors should be made smoke tight in compliance with Section 18.3.7.8.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to assure that smoke barriers are constructed as required. Section 19.3.7.5 requires that openings in smoke barriers be protected by fire rated glazing; or wired glass vision panels in steel frames.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 12/10/13 revealed that the smoke barrier door(s) 3-32-002 on the third floor, which is rated for 45 minutes, has non rated glass vision panels.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to assure that smoke barriers are constructed as required. Section 19.3.7.5 requires that openings in smoke barriers be protected by fire rated glazing; or wired glass vision panels in steel frames.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 12/10/13 at approximately 1:00 pm revealed that the smoke barrier door(s) # 1.109.002 to Nutrition & Food services and smoke barrier door(s) #1-24-001 to the Intervention Suite on the first floor are designated smoke barriers that have non rated glass vision panels.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

While conducting the facility tour during the afternoon of 12/11/13, it was observed that the Shower Room, located next to the Group Room on the first floor, is equipped with Electric panels for door alarms. This room containing electric equipment should be separated from other areas in accordance with Section 19.3.2.1.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are properly enclosed.

THE FINDINGS INCLUDE:
Observations while touring the facility on 12/10/13 revealed the following:

1. The inactive leaf of the set of corridor doors' labeled #2-02-801, does not engage in the door header.
2. The corridor door at the Electrical Room labeled #2-05-802, has a disconnected door closer; in addition, three ? " diameter holes in the door slab remain where a magnetic lock was removed from the door, rendering the door non-smoke tight.
3. The corridor door at the Bio-hazard Room, labeled #2-02-501, does not engage in the door frame when released from the open position.

These items should be repaired to ensure compliance with Section 19.3.2.1.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations during the morning hours of 12/11/13, the facility was not in compliance with NFPA 99, Section 10-3.1.1 which requires health care laboratories to be separated from surrounding health care areas and from exit corridors by a fire resistance construction with a minimum rating of 1 hour, and all openings protected by 3/4 hour assemblies.


THE FINDINGS INCLUDE:

Door #1-01-00, which leads from the Bio Med Engineering area to the laboratory, was not rated for 45 minutes as required by NFPA 99.
This was acknowledged by facility personnel during the tour an by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that exits are separated from other parts of the building as required. Section 7.1.3.2.1 requires an exit to be separated from other parts of the building; the separating construction shall meet the requirements of Section 8.2 and the following.
(a) The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

THE FINDINGS INCLUDE:
Observations while touring the facility on 12/11/13 revealed that the exit door to the stair, located across from Room 114, did not latch in it's frame as required by Section 8.2.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that exits are separated from other parts of the building as required. Section 7.1.3.2.1 requires an exit to be separated from other parts of the building; the separating construction shall meet the requirements of Section 8.2 and the following:
(a) The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

THE FINDINGS INCLUDE:
Observations while touring the facility on 12/10/13 revealed the following:

1. The second floor level Stair "A" enclosure is incomplete as the two hour wall, noted on the facility plans dated September 2013, has several unsealed penetration. The north corridor wall separating the South Mechanical Room (#2-09-000) and the Recovery HVAC Room (#2-11-000) from the corridor stair enclosure, and the north Chapel and Chapel Vestibule wall, separating the Chapel area and the North Mechanical Room ' s Interstitial Space stair enclosure have several voided areas where the gypsum wallboard (GWB) meets the concrete deck above. In addition, the HVAC ducts penetrating the Chapel and Chapel Vestibule are not equipped with fire dampers.

2. The stair door 2-06-301 is adequately labeled as a 1 1/2 hour fire rated door. However, the integrity of the door has been compromised as a result of three 1/2" holes in the door.

3. The third floor stairwell "B" door will not self latch.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by facility staff, the facility failed to assure egress routes are maintained. NFPA 101, section 7.1.3.2.1 states that where this code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(a) The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating. Door assembly in 2-hour fire resistance separation must be at least 90 minutes.

THE FINDINGS INCLUDE:

Observations on the morning of 12/11/13 revealed that the stairwell door from the 5th floor "K" stairwell did not self close and latch as required. The closing device was too slow.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that the discharge from exits is in accordance with Chapter 7. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/11/13 revealed the following :

1. Basement Level - Treadmills were located in the path of egress from the Pulmonary Rehab area.

2. Basement Level - Abandoned batteries were located on the exterior stairway which leads from the basement level to grade on the IT end of the building.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that the discharge from exits is in accordance with Chapter 7 and means of egress components in accordance with Section 7-2. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.2.5.2 requires existing ramps to have a maximum slope of 1 inch rise for every 10 inch run.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/10/13 revealed the following :

1. The "D" stair exterior exit discharge has several loose and unstable bricks on the stair treads on the 5th of six stairs, rendering the path of exit unsafe due to a trip hazard.

2. The second means of egress from the Medical Library was not free of impediments due to the storage of four 5 gallon water jugs and miscellaneous garments hung on the wall.

Observation while touring the facility on 12/11/13.

3. The second floor means of egress from the Medical Oncology area to stairwell "H" has a ramp leading to the stairwell. The ramp pitch is 1 inch rise for every 4 inch run, making the slope too steep.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

NOTE: Item #3 does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

Based on observations, the facility failed to ensure that corridors are at least 8 feet wide. CMS S&C-04-41 states that original corridor widths cannot be diminished by any chairs, tables, filling cabinets or any not in use carts or janitorial equipment or devices affixed to the wall that exceed 3.5 inches in thickness. Section 7.3.2 states the width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 3 1/2 in. (8.9 cm) on each side shall be permitted at 38 in. (96 cm) and below.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/10/13 revealed the following:

Several wall mounted fold down charting stations installed on second and third floor level corridor walls reduced the eight (8) foot corridors to 5'-1" when fully open. Although these charting stations are equipped with closing devices, the shelves did not automatically close when released from the fully open position. These devices were typical of those noted along the corridor walls at the following patient rooms: #2-05-203, #2-05-201, #2-05-211, #2-05-213, #2-05-212, #2-05-210, and #2-02-202.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility did not assure that suites of rooms meet the requirements.
Section 18.2.5.7 requires suites of rooms, other than patient sleeping rooms, to not exceed 10,000 square feet in size.

THE FINDINGS INCLUDE:

Mugar Building - Cardiac Cath Lab Suite:

Observations on the afternoon of 12/11/13 revealed that this suite is 14,800 square feet in size.

NOTE: This Item had met the FSES when appiled in Janurary, 2010.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

Based on observations, the facility did not assure that suites of rooms meet the requirements.
Section 19.2.5.7 requires suites of rooms, other than patient sleeping rooms, to not exceed 10,000 square feet in size.

THE FINDINGS INCLUDE:

Main Building - Operating Rooms:

1. Observations on the morning of 12/11/13 revealed that this suite is 17,758 square feet in size.

Main Building - Emergency Department:

2. Observations on the morning of 12/11/13 revealed that this suite is 15,781 square feet in size.


NOTE: These items do not meet NFPA 101 Life Safety Code, 2000 edition; however they would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

These item had met the FSES when applied in January, 2010.


This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observation, patient area doors are not arranged to open as required. Section 19.2.2.2.2, exception No. 1 permits key-locking devices that restrict access to the room from the corridor and that are operable only by staff, provided such devices do not restrict egress from the room.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/10/13 revealed the following:

1. Unoccupied patient room doors on the second and third floor level South Building, termed the "Over Flow Units " by hospital staff, are equipped with pad locks and wire cable. The pad locks are utilized to lock the unoccupied patient bedroom doors from the corridor side. This is accomplished by utilizing wire cable around the corridor handrail and the corridor side door handle and securing it with a pad lock. This was specifically noted on rooms #2-05-203, #2-05-201, #2-05-211, #2-05-213, #2-05-212, #2-05-210, and #2-02-202.

On 12/12/13 when some of these rooms were occupied by patients, the cable and padlock were left hanging on the corridor handrail allowing these doors to be re-locked on the corridor side.

2. The second floor level patient bathroom corridor doors labeled #2-02-606, #2-02-605, and #2-02-604 are equipped with hasp type locks, with pad locks on the corridor side of the door.

These locks that are provided on the doors prevent egress from the rooms.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. Section 8.2.3.2.3.1 requires every opening in a fire barrier to be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening in a 2-hour fire barrier are required to have a 1-1/2-hour fire protection rating. NFPA 80, Section 2.1.4.1 requires self-closing doors to swing easily and freely and to be equipped with a closing device to cause the door to close and latch each time it is opened. Section 2.4.1.4 requires all closing mechanisms to be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

THE FINDINGS INCLUDE:

Based on observations on the morning of 12/11/13, there were voids in the fire barrier wall above the fire barrier doors on the 3rd floor which lead to the Ayling Building.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground.

THE FINDINGS INCLUDE:

During the afternoon hours of 12/10/13 while touring the facility, it was observed that the third floor level connector which leads into the Mugar Building has a set of double doors which also act as a 2-hour horizontal exit. The gap between the two door are greater than 1/8 inch and does not latch tight. This does not meet the requirements of Section 7.2.4.3.1.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

A. Based on observations and confirmed by staff, the facility failed to ensure that the facility was provided with complete sprinkler protection. Section 19.1.6.2 requires buildings classified as Type II (000) construction to be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.


THE FINDINGS INCLUDE:
Based on observations on the afternoon of 12/11/13, it was noted that the following areas on the first floor were not provided with sprinkler protection:

- Shower Room #4,
- the closet of Room #5, and
- the closet of Room #11.


B. Based on observations, the facility failed to ensure that automatic sprinklers are installed in accordance with NFPA 13 Section 5-6.4.1.1 (1999 edition). Section 5-6.4.1.1 requires the distance between the sprinkler deflector and the ceiling (under unobstructed construction) shall be a minimum of 1 in. and a maximum of 12 in.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon 12/11/13 revealed that a large percentage of ceiling tiles had been removed from the ceiling in the basement level. The ceiling grid is in place but the tiles have been removed. The sprinkler heads which are in place are greater than 12" from the deck above and facing in a downward position.


C. Based on observations on 12/11/13, there were several rooms in the basement which contained moderate quantities of combustibles which did not exceed 8 feet as described by NFPA 13, Section 2-1.2.1. Ordinary Hazards are required to be protected with adequate sprinkler protection in accordance with NFPA 13, Section 7-2.
THE FINDINGS INCLUDE:
Moderate quantities of combustibles were stored through the basement in various rooms. The sprinkler system provided is a light hazard design (.10 gpm/ft 2 for an area of operation of 1500 ft 2). If this storage is to remain, the sprinkler system should be reinforced to provide adequate coverage for an Ordinary Hazard (.15 gpm/ft 2 for an area of operation of 1500 ft 2) in accordance with NFPA 13.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that automatic sprinklers are installed throughout the premises. Section 19.3.5.1 states where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. This facility is required to be fully sprinklered to meet the numerous exceptions which are utilized by installation of the automatic sprinkler system. NFPA 13, Section 5-6.4.1.1 requires the distance between the sprinkler deflector and the ceiling (under unobstructed construction) to be a minimum of 1 in. and a maximum of 12 in.

NFPA 13 Section 5-13.11states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/10/13 revealed the following:

1. The second floor level mock operating room, formerly Medical Records Office, labeled 2-02-407B has several 2' X 2' in-lay ceiling tiles removed, leaving the distance from the sprinkler head's deflector more than 24" to the deck above.

2. Due to plain glass vision panels in corridor walls, the Main Building is required to be fully sprinkled. The following areas were not provided with sprinkler protection:

- The Administration Restroom 2-06-601 on the 2nd floor.
- The Administrative Office Supply Closets 2-06-407 and 2-06-410.
- The IT Closet 2-06-410

3. The non-sprinklered 3rd floor level electrical room #3-13-800 (S3 1012) is not separated by a 2-hour fire rating. The room is currently equipped with a non-rated wood door.

4. The non-sprinklered 2nd floor Sterile Processing Department's Electric Closet, which contains the controls for the dumb waiters, is not separated by a 2-hour fire rating. The closet is currently equipped with a pair of unrated doors.

5. The South Mechanical 2-14-000 , which contains combustible storage, is not provided with sprinkler coverage in front of the electrical panels.

6. Electrical Room 2-11-800, which has an inadequate fire protection rating due to voids, is not provided with sprinkler protection..

7. The first floor Mechanical Room 1-03-700, which contains combustible storage, is not provided with sprinkler protection.


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8. The basement Sewer Ejector Control Panel Closet B-12-701 was not a rated room nor was it provided with sprinkler protection.

9. The third floor main hospital electrical closet # 3-06-802 does not have a ceiling, and has a sprinkler head that is 24 inches below the deck above. The head is facing towards the floor.


This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25
Section 9-4.4.2.2 states each dry pipe valve shall be trip tested annually during warm weather.

Exception: Dry pipe valves protecting freezers shall be trip tested in a manner that does not introduce moisture into the piping in the freezers..

THE FINDINGS INCLUDE:

While conducting the record review process, on the morning of 12/11/13 at approximately 11:45 am, it was revealed that an annual trip test of the facility's dry-pipe valve was not conducted. Documentation revealed that a three year full flow test was conducted on 6/28/11 but there was no evidence to substantiate the annual testing.

The finding was confirmed by both the facility's sprinkler technician and the facility's Director of Engineering during the record review process.

Based on record review the facility failed to assure that the automatic sprinkler system is maintained, tested, and inspected as required by NFPA #25. NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.

THE FINDINGS INCLUDE:

-While conducting the record review process, on the morning of 12/11/13 at approximately 11:30 am, it was revealed that the main alarm valve to the sprinkler riser located in the radiation therapy records room has not been internally inspected within the past five (5) years.

The finding was confirmed by both the facility's sprinkler technician and the facilities Director of Engineering during the record review process.

Based on observations and confirmed by staff, the facility failed to ensure compliance with NFPA 90A. Section 3.3.1.1 requires approved fire dampers to be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more. Section 3.3.1.2 requires approved fire dampers to be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected. Section 2.3.4.1 requires a service opening to be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within. Section 2.3.8 requires fire dampers to be installed in conformance with the conditions of their listings. Section 3.4.6.2 requires fire dampers, including their sleeves; smoke dampers; and ceiling dampers to be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions.

THE FINDINGS INCLUDE:

During the morning hours of 12/11/13 while touring the facility, it was noted that two 8"round ducts penetrated the 2 hour fire barrier wall above doors 3-04-000. The ducts noted have no access panels to determine if fire dampers are in fact installed and/or maintained as required.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility was not in compliance with NFPA 99, 1999 edition, Section 4-3.1.1.9. Section 4-3.1.1.9 (b) which states the compressor intake for a Medical Air Compressor Supply System, except as provided in 4-3.1.1.9(b)1, the intake to medical air compressors shall be located outdoors above roof level a minimum distance of 10 ft (3 m) from any door, window, exhaust, other intake, or opening in the building, and a minimum distance of 20 ft (6 m) above the ground. Intakes shall be turned down and screened or otherwise be protected against the entry of vermin or water, with screening that shall be fabricated or composed of a noncorrosive material such as stainless steel or other suitable material. Compressor intake piping shall be of materials approved for vacuum piping under 4-3.2.2.2(a) that will not add contaminants in the form of particulate matter, odor, or other gases. (See C-4.2.6.)

Section 4-3.1.1.9(b)1 requires that if a source is available that is equal to or better than outside air (air already filtered for use in operating room ventilating systems, for example), it shall be permitted to be used for the medical air compressors. This alternate source of supply air must be available on a continuous 24-hour-per-day, 7-day-per-week basis. Ventilating systems having fans with motors or drive belts located in the air stream shall not be used as a source of medical air intake.

THE FINDINGS INCLUDE:

Based on observation and interview with facility personnel on 12/12/13, the compressor intake for the medical air is provided through a mechanical ventilation system which also feeds the operating rooms. This scenario is not acceptable as per NFPA 99, Section 4-3.1.1.9(b)1 as the motor for the intake is located in the air stream.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

A. Based on observations, the facility failed to ensure that the discharge from exits is in accordance with Chapter 7. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. In areas where there are climatic conditions such as rain or snow which could render a yard or unpaved area unusable, permanent sidewalk must be provided.

THE FINDINGS INCLUDE:

While conducting the facility tour on the afternoon of 12/11/13 at about 3:30 PM, it was revealed that the back exit is designated as an exit had about one (1) inch of snow and ice on the stairs and walkway.

B .Based on record review the facility failed to assure that the automatic sprinkler system is maintained, tested, and inspected as required by NFPA #25. NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.

THE FINDINGS INCLUDE:

While conducting the facility tour on the afternoon of 12/11/13 , it was revealed that the automatic sprinkler systems two (2) main alarm valves have not been internally inspected within the past five (5) years. A review of inspection reports made available on the same date revealed the same.

The finding was confirmed by both the facility's sprinkler technician and the facilities Director of Engineering during the record review process.

Based on observations and confirmed by staff, the facility failed to maintain corridor doors to: - resist the passage of smoke,
- ensure that there are no impediments to the closing of doors protecting corridor openings ( NOTE: Hold-open devices that release when the door is pushed or pulled - no manual unlatching or releasing action necessary to close) are permitted, such as friction catches or magnetic catches, and
- ensure that corridor doors close completely and latch tightly in their frames.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/11/13 revealed the following the first floor corridor door to Room #5 was not smoke tight due to three (3), one half inch ( ½ " ) diameter holes located around the door knob.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to maintain corridor doors to: - resist the passage of smoke,
- ensure that there are no impediments to the closing of doors protecting corridor openings ( NOTE: Hold-open devices that release when the door is pushed or pulled - no manual unlatching or releasing action necessary to close) are permitted, such as friction catches or magnetic catches, and
- ensure that corridor doors close completely and latch tightly in their frames.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/10/13 revealed the following:

1. Three (3), one half inch ( ½ " ) diameter holes are located in the second floor corridor door labeled #2-02- 401 (Managers office).

2. Door wedges are utilized on the second floor corridor doors labeled #2-01-401 and #2-01-402.

3. The corridor doors to the Staff Lounge 4-01-300 on the fourth floor and the Staff Lounge 2-06-403 on the second floor were equipped with magnetic devices to keep the doors closed. However, these devices release upon activation of the fire alarm. Therefore, the corridor doors to these rooms are not provided with a means for keeping the door closed in accordance with Section 19-3.6.3.2.

4. The corridor doors to Room #'s 4-02-213 and 4-02-207 on the fourth floor did not latch in their frames.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier walls are properly maintained.

THE FINDINGS INCLUDE:

During the morning hours of 12/11/13 while touring the facility, it was observed that smoke barrier walls in the following areas have unsealed penetrations:

1. 1st floor - Above the double doors, # 1-11-000, that lead into the Emergency Department, there are two, 2- inch conduits not sealed and two, 2-inch holes in the wall.

2. 1st floor - Above the door that leads into the MRI area , there is 2 foot by 3 foot hole in the wall.

3. 1st floor - Various voids in the smoke barrier wall by doors #1-01-001.

4. 3rd floor - Two voids in the smoke barrier to the CUICU above doors #3-10-000 which were not sealed.

5. 3rd floor - Three voids in the smoke barrier wall above smoke barrier doors #3-13-000.

6. 4th floor - Voids around the pipe penetrations in the corridor wall above door #4-02-801.

These voids should be sealed to provide at least a one half hour fire resistance rating in accordance with 8.3.


This was acknowledged by facility personnel during the tour an by Administration and the Director of Engineering during the exit interview process.

Based on observations, plan review, and confirmed by staff, the facility failed to provide smoke barrier walls with a 1-hour fire rating assembly.

THE FINDINGS INCLUDE:

During the morning hours of 12/11/13 while touring the facility, it was observed that the smoke barrier walls located in the following areas had voids:

1) 5th floor - Above the center core door there were 5 data lines not sealed.

2) 5th floor - Above the cross corridor door located near room 513, a void is located behind the 2 inch sprinkler pipe.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier doors are maintained in the proper operating condition and in compliance with Section 18.3.7.8.

THE FINDINGS INCLUDE:

During the morning hours of 12/11/13 while touring the facility, it was observed that the smoke barrier doors would not close tight.

1) 6th floor center core - The latching device prevents the smoke barrier door from closing tight.

2) 5th floor center core - The smoke barrier door is rubbing against the door frame preventing the door from closing tight.

3) 4th floor cross corridor - The smoke barrier door near room 413 is rubbing against the frame preventing the door from closing tight.

4) The smoke barrier doors, identified as 3-32-002, have a gap greater than 1/8 inch. These doors should be made smoke tight in compliance with Section 18.3.7.8.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to assure that smoke barriers are constructed as required. Section 19.3.7.5 requires that openings in smoke barriers be protected by fire rated glazing; or wired glass vision panels in steel frames.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 12/10/13 revealed that the smoke barrier door(s) 3-32-002 on the third floor, which is rated for 45 minutes, has non rated glass vision panels.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to assure that smoke barriers are constructed as required. Section 19.3.7.5 requires that openings in smoke barriers be protected by fire rated glazing; or wired glass vision panels in steel frames.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 12/10/13 at approximately 1:00 pm revealed that the smoke barrier door(s) # 1.109.002 to Nutrition & Food services and smoke barrier door(s) #1-24-001 to the Intervention Suite on the first floor are designated smoke barriers that have non rated glass vision panels.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

While conducting the facility tour during the afternoon of 12/11/13, it was observed that the Shower Room, located next to the Group Room on the first floor, is equipped with Electric panels for door alarms. This room containing electric equipment should be separated from other areas in accordance with Section 19.3.2.1.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are properly enclosed.

THE FINDINGS INCLUDE:
Observations while touring the facility on 12/10/13 revealed the following:

1. The inactive leaf of the set of corridor doors' labeled #2-02-801, does not engage in the door header.
2. The corridor door at the Electrical Room labeled #2-05-802, has a disconnected door closer; in addition, three ½ " diameter holes in the door slab remain where a magnetic lock was removed from the door, rendering the door non-smoke tight.
3. The corridor door at the Bio-hazard Room, labeled #2-02-501, does not engage in the door frame when released from the open position.

These items should be repaired to ensure compliance with Section 19.3.2.1.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations during the morning hours of 12/11/13, the facility was not in compliance with NFPA 99, Section 10-3.1.1 which requires health care laboratories to be separated from surrounding health care areas and from exit corridors by a fire resistance construction with a minimum rating of 1 hour, and all openings protected by 3/4 hour assemblies.


THE FINDINGS INCLUDE:

Door #1-01-00, which leads from the Bio Med Engineering area to the laboratory, was not rated for 45 minutes as required by NFPA 99.
This was acknowledged by facility personnel during the tour an by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that exits are separated from other parts of the building as required. Section 7.1.3.2.1 requires an exit to be separated from other parts of the building; the separating construction shall meet the requirements of Section 8.2 and the following.
(a) The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

THE FINDINGS INCLUDE:
Observations while touring the facility on 12/11/13 revealed that the exit door to the stair, located across from Room 114, did not latch in it's frame as required by Section 8.2.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that exits are separated from other parts of the building as required. Section 7.1.3.2.1 requires an exit to be separated from other parts of the building; the separating construction shall meet the requirements of Section 8.2 and the following:
(a) The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

THE FINDINGS INCLUDE:
Observations while touring the facility on 12/10/13 revealed the following:

1. The second floor level Stair "A" enclosure is incomplete as the two hour wall, noted on the facility plans dated September 2013, has several unsealed penetration. The north corridor wall separating the South Mechanical Room (#2-09-000) and the Recovery HVAC Room (#2-11-000) from the corridor stair enclosure, and the north Chapel and Chapel Vestibule wall, separating the Chapel area and the North Mechanical Room ' s Interstitial Space stair enclosure have several voided areas where the gypsum wallboard (GWB) meets the concrete deck above. In addition, the HVAC ducts penetrating the Chapel and Chapel Vestibule are not equipped with fire dampers.

2. The stair door 2-06-301 is adequately labeled as a 1 1/2 hour fire rated door. However, the integrity of the door has been compromised as a result of three 1/2" holes in the door.

3. The third floor stairwell "B" door will not self latch.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by facility staff, the facility failed to assure egress routes are maintained. NFPA 101, section 7.1.3.2.1 states that where this code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(a) The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating. Door assembly in 2-hour fire resistance separation must be at least 90 minutes.

THE FINDINGS INCLUDE:

Observations on the morning of 12/11/13 revealed that the stairwell door from the 5th floor "K" stairwell did not self close and latch as required. The closing device was too slow.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that the discharge from exits is in accordance with Chapter 7. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/11/13 revealed the following :

1. Basement Level - Treadmills were located in the path of egress from the Pulmonary Rehab area.

2. Basement Level - Abandoned batteries were located on the exterior stairway which leads from the basement level to grade on the IT end of the building.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that the discharge from exits is in accordance with Chapter 7 and means of egress components in accordance with Section 7-2. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.2.5.2 requires existing ramps to have a maximum slope of 1 inch rise for every 10 inch run.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/10/13 revealed the following :

1. The "D" stair exterior exit discharge has several loose and unstable bricks on the stair treads on the 5th of six stairs, rendering the path of exit unsafe due to a trip hazard.

2. The second means of egress from the Medical Library was not free of impediments due to the storage of four 5 gallon water jugs and miscellaneous garments hung on the wall.

Observation while touring the facility on 12/11/13.

3. The second floor means of egress from the Medical Oncology area to stairwell "H" has a ramp leading to the stairwell. The ramp pitch is 1 inch rise for every 4 inch run, making the slope too steep.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

NOTE: Item #3 does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

Based on observations, the facility failed to ensure that corridors are at least 8 feet wide. CMS S&C-04-41 states that original corridor widths cannot be diminished by any chairs, tables, filling cabinets or any not in use carts or janitorial equipment or devices affixed to the wall that exceed 3.5 inches in thickness. Section 7.3.2 states the width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 3 1/2 in. (8.9 cm) on each side shall be permitted at 38 in. (96 cm) and below.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/10/13 revealed the following:

Several wall mounted fold down charting stations installed on second and third floor level corridor walls reduced the eight (8) foot corridors to 5'-1" when fully open. Although these charting stations are equipped with closing devices, the shelves did not automatically close when released from the fully open position. These devices were typical of those noted along the corridor walls at the following patient rooms: #2-05-203, #2-05-201, #2-05-211, #2-05-213, #2-05-212, #2-05-210, and #2-02-202.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility did not assure that suites of rooms meet the requirements.
Section 18.2.5.7 requires suites of rooms, other than patient sleeping rooms, to not exceed 10,000 square feet in size.

THE FINDINGS INCLUDE:

Mugar Building - Cardiac Cath Lab Suite:

Observations on the afternoon of 12/11/13 revealed that this suite is 14,800 square feet in size.

NOTE: This Item had met the FSES when appiled in Janurary, 2010.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

Based on observations, the facility did not assure that suites of rooms meet the requirements.
Section 19.2.5.7 requires suites of rooms, other than patient sleeping rooms, to not exceed 10,000 square feet in size.

THE FINDINGS INCLUDE:

Main Building - Operating Rooms:

1. Observations on the morning of 12/11/13 revealed that this suite is 17,758 square feet in size.

Main Building - Emergency Department:

2. Observations on the morning of 12/11/13 revealed that this suite is 15,781 square feet in size.


NOTE: These items do not meet NFPA 101 Life Safety Code, 2000 edition; however they would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

These item had met the FSES when applied in January, 2010.


This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observation, patient area doors are not arranged to open as required. Section 19.2.2.2.2, exception No. 1 permits key-locking devices that restrict access to the room from the corridor and that are operable only by staff, provided such devices do not restrict egress from the room.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/10/13 revealed the following:

1. Unoccupied patient room doors on the second and third floor level South Building, termed the "Over Flow Units " by hospital staff, are equipped with pad locks and wire cable. The pad locks are utilized to lock the unoccupied patient bedroom doors from the corridor side. This is accomplished by utilizing wire cable around the corridor handrail and the corridor side door handle and securing it with a pad lock. This was specifically noted on rooms #2-05-203, #2-05-201, #2-05-211, #2-05-213, #2-05-212, #2-05-210, and #2-02-202.

On 12/12/13 when some of these rooms were occupied by patients, the cable and padlock were left hanging on the corridor handrail allowing these doors to be re-locked on the corridor side.

2. The second floor level patient bathroom corridor doors labeled #2-02-606, #2-02-605, and #2-02-604 are equipped with hasp type locks, with pad locks on the corridor side of the door.

These locks that are provided on the doors prevent egress from the rooms.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. Section 8.2.3.2.3.1 requires every opening in a fire barrier to be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening in a 2-hour fire barrier are required to have a 1-1/2-hour fire protection rating. NFPA 80, Section 2.1.4.1 requires self-closing doors to swing easily and freely and to be equipped with a closing device to cause the door to close and latch each time it is opened. Section 2.4.1.4 requires all closing mechanisms to be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

THE FINDINGS INCLUDE:

Based on observations on the morning of 12/11/13, there were voids in the fire barrier wall above the fire barrier doors on the 3rd floor which lead to the Ayling Building.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground.

THE FINDINGS INCLUDE:

During the afternoon hours of 12/10/13 while touring the facility, it was observed that the third floor level connector which leads into the Mugar Building has a set of double doors which also act as a 2-hour horizontal exit. The gap between the two door are greater than 1/8 inch and does not latch tight. This does not meet the requirements of Section 7.2.4.3.1.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

A. Based on observations and confirmed by staff, the facility failed to ensure that the facility was provided with complete sprinkler protection. Section 19.1.6.2 requires buildings classified as Type II (000) construction to be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.


THE FINDINGS INCLUDE:
Based on observations on the afternoon of 12/11/13, it was noted that the following areas on the first floor were not provided with sprinkler protection:

- Shower Room #4,
- the closet of Room #5, and
- the closet of Room #11.


B. Based on observations, the facility failed to ensure that automatic sprinklers are installed in accordance with NFPA 13 Section 5-6.4.1.1 (1999 edition). Section 5-6.4.1.1 requires the distance between the sprinkler deflector and the ceiling (under unobstructed construction) shall be a minimum of 1 in. and a maximum of 12 in.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon 12/11/13 revealed that a large percentage of ceiling tiles had been removed from the ceiling in the basement level. The ceiling grid is in place but the tiles have been removed. The sprinkler heads which are in place are greater than 12" from the deck above and facing in a downward position.


C. Based on observations on 12/11/13, there were several rooms in the basement which contained moderate quantities of combustibles which did not exceed 8 feet as described by NFPA 13, Section 2-1.2.1. Ordinary Hazards are required to be protected with adequate sprinkler protection in accordance with NFPA 13, Section 7-2.
THE FINDINGS INCLUDE:
Moderate quantities of combustibles were stored through the basement in various rooms. The sprinkler system provided is a light hazard design (.10 gpm/ft 2 for an area of operation of 1500 ft 2). If this storage is to remain, the sprinkler system should be reinforced to provide adequate coverage for an Ordinary Hazard (.15 gpm/ft 2 for an area of operation of 1500 ft 2) in accordance with NFPA 13.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that automatic sprinklers are installed throughout the premises. Section 19.3.5.1 states where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. This facility is required to be fully sprinklered to meet the numerous exceptions which are utilized by installation of the automatic sprinkler system. NFPA 13, Section 5-6.4.1.1 requires the distance between the sprinkler deflector and the ceiling (under unobstructed construction) to be a minimum of 1 in. and a maximum of 12 in.

NFPA 13 Section 5-13.11states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/10/13 revealed the following:

1. The second floor level mock operating room, formerly Medical Records Office, labeled 2-02-407B has several 2' X 2' in-lay ceiling tiles removed, leaving the distance from the sprinkler head's deflector more than 24" to the deck above.

2. Due to plain glass vision panels in corridor walls, the Main Building is required to be fully sprinkled. The following areas were not provided with sprinkler protection:

- The Administration Restroom 2-06-601 on the 2nd floor.
- The Administrative Office Supply Closets 2-06-407 and 2-06-410.
- The IT Closet 2-06-410

3. The non-sprinklered 3rd floor level electrical room #3-13-800 (S3 1012) is not separated by a 2-hour fire rating. The room is currently equipped with a non-rated wood door.

4. The non-sprinklered 2nd floor Sterile Processing Department's Electric Closet, which contains the controls for the dumb waiters, is not separated by a 2-hour fire rating. The closet is currently equipped with a pair of unrated doors.

5. The South Mechanical 2-14-000 , which contains combustible storage, is not provided with sprinkler coverage in front of the electrical panels.

6. Electrical Room 2-11-800, which has an inadequate fire protection rating due to voids, is not provided with sprinkler protection..

7. The first floor Mechanical Room 1-03-700, which contains combustible storage, is not provided with sprinkler protection.


17078


8. The basement Sewer Ejector Control Panel Closet B-12-701 was not a rated room nor was it provided with sprinkler protection.

9. The third floor main hospital electrical closet # 3-06-802 does not have a ceiling, and has a sprinkler head that is 24 inches below the deck above. The head is facing towards the floor.


This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25
Section 9-4.4.2.2 states each dry pipe valve shall be trip tested annually during warm weather.

Exception: Dry pipe valves protecting freezers shall be trip tested in a manner that does not introduce moisture into the piping in the freezers..

THE FINDINGS INCLUDE:

While conducting the record review process, on the morning of 12/11/13 at approximately 11:45 am, it was revealed that an annual trip test of the facility's dry-pipe valve was not conducted. Documentation revealed that a three year full flow test was conducted on 6/28/11 but there was no evidence to substantiate the annual testing.

The finding was confirmed by both the facility's sprinkler technician and the facility's Director of Engineering during the record review process.

Based on record review the facility failed to assure that the automatic sprinkler system is maintained, tested, and inspected as required by NFPA #25. NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.

THE FINDINGS INCLUDE:

-While conducting the record review process, on the morning of 12/11/13 at approximately 11:30 am, it was revealed that the main alarm valve to the sprinkler riser located in the radiation therapy records room has not been internally inspected within the past five (5) years.

The finding was confirmed by both the facility's sprinkler technician and the facilities Director of Engineering during the record review process.

Based on observations and confirmed by staff, the facility failed to ensure compliance with NFPA 90A. Section 3.3.1.1 requires approved fire dampers to be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more. Section 3.3.1.2 requires approved fire dampers to be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected. Section 2.3.4.1 requires a service opening to be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within. Section 2.3.8 requires fire dampers to be installed in conformance with the conditions of their listings. Section 3.4.6.2 requires fire dampers, including their sleeves; smoke dampers; and ceiling dampers to be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions.

THE FINDINGS INCLUDE:

During the morning hours of 12/11/13 while touring the facility, it was noted that two 8"round ducts penetrated the 2 hour fire barrier wall above doors 3-04-000. The ducts noted have no access panels to determine if fire dampers are in fact installed and/or maintained as required.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility was not in compliance with NFPA 99, 1999 edition, Section 4-3.1.1.9. Section 4-3.1.1.9 (b) which states the compressor intake for a Medical Air Compressor Supply System, except as provided in 4-3.1.1.9(b)1, the intake to medical air compressors shall be located outdoors above roof level a minimum distance of 10 ft (3 m) from any door, window, exhaust, other intake, or opening in the building, and a minimum distance of 20 ft (6 m) above the ground. Intakes shall be turned down and screened or otherwise be protected against the entry of vermin or water, with screening that shall be fabricated or composed of a noncorrosive material such as stainless steel or other suitable material. Compressor intake piping shall be of materials approved for vacuum piping under 4-3.2.2.2(a) that will not add contaminants in the form of particulate matter, odor, or other gases. (See C-4.2.6.)

Section 4-3.1.1.9(b)1 requires that if a source is available that is equal to or better than outside air (air already filtered for use in operating room ventilating systems, for example), it shall be permitted to be used for the medical air compressors. This alternate source of supply air must be available on a continuous 24-hour-per-day, 7-day-per-week basis. Ventilating systems having fans with motors or drive belts located in the air stream shall not be used as a source of medical air intake.

THE FINDINGS INCLUDE:

Based on observation and interview with facility personnel on 12/12/13, the compressor intake for the medical air is provided through a mechanical ventilation system which also feeds the operating rooms. This scenario is not acceptable as per NFPA 99, Section 4-3.1.1.9(b)1 as the motor for the intake is located in the air stream.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

A. Based on observations, the facility failed to ensure that the discharge from exits is in accordance with Chapter 7. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. In areas where there are climatic conditions such as rain or snow which could render a yard or unpaved area unusable, permanent sidewalk must be provided.

THE FINDINGS INCLUDE:

While conducting the facility tour on the afternoon of 12/11/13 at about 3:30 PM, it was revealed that the back exit is designated as an exit had about one (1) inch of snow and ice on the stairs and walkway.

B .Based on record review the facility failed to assure that the automatic sprinkler system is maintained, tested, and inspected as required by NFPA #25. NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.

THE FINDINGS INCLUDE:

While conducting the facility tour on the afternoon of 12/11/13 , it was revealed that the automatic sprinkler systems two (2) main alarm valves have not been internally inspected within the past five (5) years. A review of inspection reports made available on the same date revealed the same.

The finding was confirmed by both the facility's sprinkler technician and the facilities Director of Engineering during the record review process.