HospitalInspections.org

It was observed by Inspector 37696 and Director of Construction Services for EMMC that the guard on the landings in the convince stair in Haskell does not meet NFPA 101 (2012) 7.2.2.4.5 and shall be 42" high and shall have intermediate rails or an ornamental pattern such that a sphere 4 in. (100 mm) in diameter is not able to pass through any opening up to a height of 34 in.

It was observed by Inspector 37696 and Director of Construction Services for EMMC that the main entrance and side exit to the Vascular Care Center is not protected from the parking garage by rated doors or rated sidelights

Based on observation of the surveyor 35163 and 37694 on 1/30/17, in the presence of the maintenance manager the following was not met:

1. Tel/Data room located near nursing station in the penobscot building level 7, had fire proofing that was missing and had been scraped off where hangers were attached.

2. The essential electrical room located in penobscot 6 building, had missing fire proofing on some of the structural beams and missing fire stopping material.

3. The essential electrical room located in penobscot building level 5 had open electrical conduit with no fire stopping material present.

4. The normal electrical room located in penobscot building level 5 had gaps around vent with no fire stopping material present.

5. Med-room located in business office space of grant 1 building had penetrations in the 1 hr. wall with no fire stopping present

Between 1-30-2017 and 1-31-2017 while surveying this facility with a facilities representative and surveyor 37696 this surveyor did observe:

Fire proofing missing from structural steel located on the 4th floor of the Keagan building in the elevator machine room near Life Flight.

3rd floor Keagan Building - Sprinkler room: Several floor penetrations not sealed.

Second floor Keagan Building-Materials Store Room: several areas of the structural steel is missing fire proofing material.

Haskell Building second floor: 1. Pipe chase near elevators has several floor penetrations.
2. Data closet in Resporatory medicine; several floor penetrations required to be sealed.




37696


It was observed by Inspector 37696 and Director of Construction Services for EMMC areas of fire poofing has been removed from the structural steel of the buildings in the following areas:
Kegan 4 mechanical room, throughout this space including the air intake spaces (both existing and old) on both columns & beams
Kegan in mechanical room housing air handler #41, large amounts of fire proofing is missing off structural steel columns








37694

While inspecting this facility on January 30th, 2017 with the Facilities Manager and surveyor 35163, this surveyor did observe:
1. The Medical Electrical closet on Penobscot 6 does not meet current Construction Type 3(222) as there is missing fireproofing on the I-beam.

While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.The AHU-11 mechanical room of the Breast and Osteoporosis Center does not meet current Construction Type 3(222) as there is missing fireproofing above the door frame.

It was observed by Inspector 37696 and Director of Construction Services for EMMC that items were being stored in the corridors in the following locations:

a. Kegan: corridor from the flight deck to life flight elevator
2nd stairwell off flight deck is being use for janitorial supplies
end of hall outside Life Flight office door,

b. Kegan 2: by Wound Clinic back door; blanket warmer & chair/BP cuff in side exit corridor
nurses work stations in corridors have desks against the wall with rolling chairs that go into the path of egress.
exit 273 partially blocked by carts stored by the exit partially blocking










34673

Between 1-30-2017 and 1-31-2017 while surveying this facility with a facilities representative and surveyor 37696 this surveyor did observe:

Fans located in the Fitness center (2nd Floor Keagan Building) shall be mounted a minimum of 6'-8" of the finished floor.




35163


Based on observation of the surveyor 35163 and 37694 on 1/30/17, in the presence of the maintenance manager the following was not met:

1. There were two pieces of furniture (ottoman seats) located in the elevator lobby on level seven of the penobscot building. The furniture was located on both sides of the corridor and was not secured to the floor or wall.

2. Corridor located outside of the surgical patient reception area on level one of the grant building, had chairs located on each side of the corridor that were not secured to the walls/floor and encroached into the egress path.




37694

While inspecting this facility on January 30th, 2017 with the Facilities Manager and surveyor 35163, this surveyor did observe:
1.The Incoming mailbox installed in the hallway by Penobscot 5 nurse's station projects 5 ¼" into the corridor. All projections less than 6' 8" above the floor may only project 4" into the corridor.
2.The Med cart storage alcove by the nurse ' s station on Penobscot 5 has a cart that protruded 15" into the hallway
While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.Exit by OR 12 shall be clear of obstructions. Wheeled cart impeding exit access.

Between 1-30-2017 and 1-31-2017 while surveying this facility with a facilities representative and surveyor 37696 this surveyor did observe:

Kelly Building floor #3- exit doors shall not be locked against egress. Dead bolt lock on these doors shall be removed.


37694

While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.Remove slide lock and dead bolt on the exit door from Cath Lab.

On 1-30-2017 During our Inspection Surveyors 16776 / 36433 and Maintenance Director observed the following violations listed below in the listed Locations.

Blaisdell P.O.: Level # 1:

1. Door's at Fire Barrier ( Rated Doors) Not Closing need to be adjusted.

______________________________________________________________________________________________________

Level # 5:


1. Exit Door # F-551 Not Closing Need to be Adjusted.

2. Office Door to the dictation Room in a Rated Corridor Missing Self Closer on the door.

3. Fire Doors from Blaisdel to P.O. ; Hole in Frame degrsdes rating of assembly. Hole in frame need to be filled in.

____________________________________________________________________________________________________

Level # 3 (C);

1. Housekeeping Door Need's a self closer.


____________________________________________________________________________________________________


On 1-31-2017 During our inspection Surveyors 16776 / 36433 / 38667 and Maintenance Director Observed the following in the locations lised below.


Grant Building:

1. Grant Stair South Level # 2 Door Not Closing and Latching.

2. Grant Stair South level # 3 Pipe chase access panal not Self - Closing , the acess panel does not positively latch.

3. Grant Stair south level # 4 Door GRT4-S438 to Level 4 Not positively Latching.

____________________________________________________________________________________________________



37696

It was observed by Inspector 37696 and Director of Construction Services for EMMC that the following corridor doors:
Kegan back corridor door to endo across from Treatment #5 does not latch
Treatment #5 door mechanism prohibits the door from latching unless it's after hours
Grant Connector cross corridor doors by Kelley 3 do not close completely due to air pressure holding them open
Kegan at Life Flight helipad level, the stair door to the corridor has a brick sitting next to it which is used to prop the stairwell door open.
Kegan 4 in electrical ATS 23, 24, 25, 29 the rated & self-closing doors between the electrical rooms was propped open with a hunk of wood.










35163

Based on observation of the surveyor 35163 and 37694 on 1/30/17, in the presence of the maintenance manager the following was not met:

1. Grant 1/CCU clean utility storage room had self closing devices that are mechanically held open and do not release upon activation of the fire alarm system.

Based on observation of the surveyor 35163 and 37694 on 1/30/17, in the presence of the maintenance manager the following was not met:

1. There was missing fireproofing material on the structural members in the stairwell between levels 7 and 8 of the penobscot building.

It was observed by Inspector 37696 and Director of Construction Services for EMMC that the following ramps are steeper than 1:20 and have an overall rise of more than 6" and require handrails that meet NFPA 101 (2012) 7.2.2.4.4
PO to Kelley 3 connector
Grant Connector at PO5 to Kelley 5

It was observed by Inspector 37696 and Director of Construction Services for EMMC that the following items mounted in the corridors protrude more than the allowable 6" (mounted prior to Nov 7, 2016) and 4" mounted after Nov 7, 2016.

Kegan 3, Bug light mounted 64" above finished floor and protrudes 8"





16732

Based on observation of surveyors 16732 and 37695 on January 31, 2017:

Grant Building Floor number 2 - pharmacy room entrance from corridor is narrowed to aprox 2 feet as there are three red carts against left wall and 3 laboratory refrigerators on the right wall.

The maintenance engineer was present during this observation



Based on observation or surveyor 16732 on February 1, 2017:

Floor Phillips PO3 in the corridor there was an infectious cart on left side of wall facing nurses station and directly across was a wheel chair open obstructing egress below 4 feet. Patient in wheel chair tried to move through the area and could not until the wheel chair was moved by patients family member.

It was observed by Inspector 37696 and Director of Construction Services for EMMC:

1) The following locations did not have a 2nd means of remote egress visibly marked with an illuminated exit sign.
Kegan 4: main corridor outside Life Flight Office
At corridor under exit sign#145
Kegan OR level: in the operating area the "Restricted Access" sign blocks the exit sign
Kegan 2: Vascular Care side exit
Kelley 3 back through PO
Kelley 5, the Grant Connection does not have directional signage to the 2 remotely located exits
Kelley 4 near KLY4-F-438B

In general the 2 remote means of egress from PO, Kelley & Haskell buildings are not well defined. Additional directional signage is required in order to adequately direct patients and the public to safety.







37694

While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.Exit sign outside Registration on Grant 1 shall be covered. It is not a part of the current path of egress.

Based on observation and record review of surveyors 37695, 16776 and 16732 on February 1, 2017

1) The helipad on top of Kagen building is used as H-1 heli pad predominantly and H-2 Helicopters on occasion. There is a landing pad that has a fixed foam extinguishing that covers the landing pad of the helicopter only. Towards State St of the helipad - the H-1 helicopters are moved to the non landing pad for storage and refueling of the helicopters. There is no fixed foam extinguishing system in this area. The refueling area currently has a ABC dry chemical fire extinguisher (40A-280BC rating) being used for the refueling. NFPA 418 advises the rooftop landing pad shall be protected by a fixed fire extinguishing system. If not fixed system then two portable foam extinguishers have a rating of 20-A:160-B shall cover the pad. Currently only half of the pad is covered with fix foam extinguishing. The non foam covered area is currently used for refueling the helicopters. NFPA 418 advises the the entire load-bearing surface intended for the touchdown and lift off (TLOF) of helicopters is to be covered. The extinguishing system was discussed in a site visit in August of 1016.

On 1-31-2017 During our Inspection Surveyors 16776 / 36433 / 38667 and Maintenance Director Observed the following violation listed below:

1. Grant Building Level # 0 Mechanical Room # AHU4 has a vertical opening approximately 4' x 12' to the floor above from level 0 to level # 1 with No ratings shown on drawings.

At Grant Building Level # 1 ICU waiting area Housekeeping closet has penetratins through the rated shaft, ( same rated shaft as mentioned above.) Rated shaft has a piece of FRP paneling covering the penetration od a 2" copper pipe.


34673

Between 1-30-2017 and 1-31-2017 while surveying this facility with a facilities representative and surveyor 37696 this surveyor did observe:

3rd floor Keagan Building- Stair # 3: The exit stair shares a common wall with an adjacent electrical room. Several areas within the stair and the electrical room need to be sealed to meet the 2 hour minimum fire resistance rating.



37696

It was observed by Inspector 37696 and Director of Construction Services for EMMC that the drywall seam behind the horizontal tube steel in Kegan Stairway #3 is not tape or sealed.



37694

While inspecting this facility on January 30th, 2017 with the Facilities Manager and surveyor 35163, this surveyor did observe:
1.Wooden cabinet attached to right wall shall be removed from the first level of Grant Stair 1.

Between 1-30-2017 and 1-31-2017 while surveying this facility with a facilities representative and surveyor 37696 this surveyor did observe:

Wall penetrations in the 4th floor elevator machine room located in the Keagan Building.

Keagan Building -3 rd floor mechanical room: numerous wall penetrations pipes, wires and structural steel. Also fire stopping at top of wall missing through out the mechanical room.

Second floor Keagan Building- Materials Store Room: 1. Fire proofing missing in several areas at the top of wall.
2. All doors shall be self-closing and positive latching.

Bio-Hazard Room - Near Fitness center: 1. Ceiling tile missing.
2. sprinkler head escutcheon cap missing.

Vascular Suite - Soiled Utility: 1. Floor penetrations required to be sealed with UL listed assembly.

Kelly Building floor #5- Soiled utility room the door shall close at all times and not be propped open. The door closing device on this door allows the door to be propped in the open position.

Haskell Building located in Respiratory Medicine: the soiled utility room requires a self-closing device on the door.




37696


It was observed by Inspector 37696 and Director of Construction Services for EMMC:
1) the following doors to do not close and/or seal properly:
Kegan 4 double door to mechanical space - same level as Life Flight Offices
Kegan 4 mechanical space, old fresh air space now being used for storage, the closing arm does not close door completely so it latches
Kegan 3: across from Endo Treatment #3, the storage room door closes but does not latch
Electrical Rm CEPP-2-M6 there is no finish hardware on the door frame. It does latch however the gap exceeds 1/2"
Kelley 4 KLY4-F-4388 door does not close completely - arm adjustment required
PO 3 soiled linen room door to have a closing mechanism and be positive latching
PO3 locker room door to be self-closing & positive latching
Kelley 3 Clean Linen room door does not latch
Soiled Linen room door does not latch
Kelley 3 Housekeeping Storage room to have self-closing door
Haskell 3 Housekeeping Closet at end of corridor closest the road to have a self-closing door
Haskell 2 PFT Lab Storage door to be self-closing and positive latching
Clean Equipment Room door to be self-closing and positive latching

2) the following hazardous areas have wall penetrations that are required to sealed with a pre-approved system of equal or higher rating that the wall/ceiling/floor
Kegan 4: mechanical room - drywall patches at beams to be finished and sealed
electrical room ATS 23,24,25,29
Gas chase closet in the IT department has large holes in the back wall that appear to go to another chase
Kegan 3 Electrical Rm CEPP-2-M6 gaps around steel
Kegan 2 Air handler #41 the walls shall be sealed at the bottom
PO stairwells
PO 3 mechanical room, wall penetrations

3) the following areas were found to have gaps and penetrations filled with spray foam
Kegan 4: mechanical space: In the ceiling, next to the column around the red pex feed lines for the Intergen IT extinguishing system
in the ceiling off to the side of fresh air vent
Gas chase closet in the IT area around the floor and ceiling penetrations

4) the wall/ceiling/floor construction of the following rooms/spaces are required to resist the passage of smoke and shall be have intact drop ceilings or walls to be continuous to the roof deck. If there is no wall base, walls to caulked or sealed at the bottom:
Kegan 4 electrical room ATS 23,24,25,29 and storage room
Kelley 4 reseat ceiling tiles in data closet in the staff breakroom
Kegan 2 Temp storage off the hallway shall have drywall on both sides of the studs and have a substantial, self-closing and positive latching door with a door/frame gap less than 1/2"





















35163


Based on observation of the surveyor 35163 and 37694 on 1/30/17, in the presence of the maintenance manager the following was not met:

1. Rear storage room located in the gift shop did not have a self closing device on the door.

2. Trash,biohazard and soiled utility room (ICU-145) located in grant 1 building, did not have a self closing device on door.

3. Soiled linen storage room located in ER would not latch. There was a screw placed in the receiver plate that did not allow for the latch function properly.

4. GRT-55 storage room had sliding door that did not latch

5. Old gift shop that was converted into a storage room (over 100 sq ft) did not have a self closing device on the doors.




37694

While inspecting this facility on January 30th, 2017 with the Facilities Manager and surveyor 35163, this surveyor did observe:
1.Penetrations from red conduit in the Normal Electrical Room on Penobscot 7 shall be sealed.

2.Two square penetrations in the wall of the Tel/Data room of Penobscot 5 shall be sealed. They are approximately 6 " x 10 " openings.

3.Multiple square penetrations in the Lighting Control Room on Penobscot 1 shall be sealed. They are approximately 6 " x 10 " .

4.Lighting control room on Penobscot 1 has penetrations around the piping that shall be sealed.
5.BlazeMaster piping installed in the electrical room by Registration on Grant 1 shall be replaced with rated assembly.

6.Wall and ceiling penetrations in electrical room by Registration on Grant 1 shall be sealed.

7.BlazeMaster piping installed in the AHU-46 mechanical room on Grant 1 shall be replaced with rated assembly.

8.Multiple penetrations through the 1 -hour fire barrier wall in the AHU-46 mechanical room on Grant 1 shall be sealed.
9.Fire barrier walls in hazardous areas shall maintain given rating. T-111, plywood and foam board installed on the 1-hour fire barrier wall in the AHU-46 mechanical room on Grant 1.

10.Rear double doors have a ¾" gap in the AHU-46 mechanical room on Grant and shall be sealed to maintain the 1-hour fire rating.

11.Multiple penetrations in the rear of the 1-hour fire barrier wall in the AHU-46 mechanical room on Grant 1.
12.Seal between the floor and the ceiling of the 2-hour fire barrier wall in the AHU-46 mechanical room on Grant 1.

13.Data closet in the ICU is missing a layer of sheetrock and has multiple large penetrations in the ceiling and walls approximately 6" x 14" . Verify the rating of the plywood attached to the wall.

14.The secondary door to the Data room in the staff locker room on Grant 1 shall be 1-hour fire rated.

While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.Seal wall penetration around the pipe in the EP Lab 2 x-ray generator room.

2.Seal wall penetration in Cardio Housekeeping Closet. It is approximately 4" x 4" .

3.Replace missing ceiling tiles in the Cardio Housekeeping Closet.
4.Multiple wall penetrations in the middle electrical closet outside Surgical Patient Reception entrance shall be sealed.

5.Conduit penetrations through the wall in the right electrical closet outside Surgical Patient Reception entrance shall be sealed.

6.Multiple ceiling penetrations in the data closet outside ED Fast track shall be sealed.
7.Switch plate cover required in ED Fast Track closet by the double doors.

8.Wall penetrations in the ED Fast Track closet by the double doors shall be sealed.

9.The 2 temporary storage areas open to the corridor in ED across from Room 16 shall be equipped with fire rated doors.

10.Storage room open to the corridor across from Room 20 and the Observation Room in the ED shall be equipped with a fire rated door.

11.Wall penetrations in the electrical room by the ED break room shall be sealed.
12.Wall penetrations in the left electrical closet across from ED check-in shall be sealed.

13.Replace missing sheetrock in the AHU-11 storage area of the Breast and Osteoporosis Center.

14.Multiple wall and ceiling penetrations in the AHU-11 storage area of the Breast and Osteoporosis Center shall be sealed.

Between 1-30-2017 and 1-31-2017 while surveying this facility with a facilities representative and surveyor 37696 this surveyor did observe:

3rd floor Keagan Building electrical closet near Endo: The sprinkler head is missing the correct escutcheon cap.

Haskell Building floor #1: sky light located above the nurses station is lacking the necessary sprinkler coverage.



37696

It was observed by Inspector 37696 and Director of Construction Services for EMMC there is no sprinkler coverage in the following areas:
Kegan OR breakroom
Kegan 2 sprinkler coverage missing from side area in vestibule to Vascular Care,
Storage closets/cupboards in the Grant Connector storage bump outs
Storage bump-outs along the Grant Connector
PO 3 nurses cubby by room 388
PO 5 IT room has 1 sprinkler head that is blocked by a column
Kelley 5 shower room across from #561
Kelley 4 side corridor by 443












35163

Based on observation of the surveyor 35163 and 37694 on 1/30/17, in the presence of the maintenance manager the following was not met:

1. Equipment room located on level 7 of the penobscot building, had storage within 18" of the sprinkler head, which would not allow for proper sprinkler pattern development

2. The essential electrical room located in the penobscot 6 building had a sprinkler head that was installed against/touching a structural beam.

3. Electrical room near registration in the grant building had exposed blazemaster/cpvc sprinkler piping.

4. There are two alcoves (old phone booths) located near entrance to CCU in grant 1 building that d not have sprinkler protection.

5. Emergency department near patient room # 19 had a alcove in the corridor with a storage cabinet and trash container located within the space and had no sprinkler protection.

6. ER entrance foyer had storage cabinets used for EMS supplies, storage was within 18' of the sprinkler heads and would not allow for proper sprinkler pattern development.

7. Sprinkler valve room located near main entrance of the penobscot building did not have a hydraulic information plate.







37694

While inspecting this facility on January 30th, 2017 with the Facilities Manager and surveyor 35163, this surveyor did observe:
1.Safety cap for the sprinkler head is missing over the nurse's station on Penobscot 6 and shall be replaced.
2.The Housekeeping closet next to the nursery on Penobscot 5 has a bin that is stacked closer than 18" from the sprinkler head.
3.Firestopping shall be applied around the standpipe in the fire cabinet in front of Penobscot 5 staff entrance.
4.The glass shelves in the gift shop on Penobscot 1 have items stacked closer than 18" from the three sprinkler heads.

5.Gift shop storage room shelves are stacked closer than 18" to the sprinkler heads.

6.Sprinkler coverage is required in the data room in the staff locker room on Grant 1.
While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.Ascutcheon cap is missing outside Procedure Room 2 & 3 in the Cath Lab and shall be replaced.

2.Ascutcheon plate shall be resealed above the desk in EP Lab 1 Procedure Room.

3.Sprinkler coverage is required in the Cardio Housekeeping Closet. Ceiling tiles currently obstruct coverage.

4.Sprinkler coverage is required in the cabinet in corridor across from Medical Imaging Holding room.

5.PICC storage room has items stacked closer than 18" to the sprinkler head.

6.Sprinkler coverage obstructed by curtain in the x-ray lobby locker area.
7.Three ascutcheon caps in the x-ray corridor are currently gapped and shall be adjusted.
8.Sprinkler coverage is required in the temporary construction space outside the ED Fast Track.
9.Ascutcheon cap is missing at the ED nurse's station and shall be replaced.
10.Ascutcheon plate shall be resealed at ED nurse ' s station.
11.Ascutcheon cap is missing outside the ED check-in and shall be replaced.
12.EMS linen cabinet has items stacked closer than 18" to the sprinkler heads.
13.Sprinkler coverage required in the temporary construction space outside Staff Entrance and Elevators by ED.
14.Ascutcheon cap missing in Room 4 of Breast and Osteoporosis Center and shall be replaced.
15.Sprinkler coverage required in GRT-0-BOC-25 closet.
16.Sprinkler coverage required in Room 1 Stereo Room of Breast and Osteoporosis Center.
17.Sprinkler coverage required in Clean room of Storage area of Breast and Osteoporosis Center.
18.Sprinkler coverage required in left closet of double door storage area of Breast and Osteoporosis Center.
19.Sprinkler coverage required in air handler room off Radiology Reading Room of Breast and Osteoporosis Center.
20.Install protective cages over the low-hanging sprinkler heads in the AHU-11 mechanical room of the Breast and Osteoporosis Center.
21.Clean Utility room by OR 12 has wheeled storage unit parked closer than 18" to the sprinkler head.
22.Ascutcheon cap is missing in the Main Preoperation Room corridor and shall be replaced.






16732

**Based on observation of surveyors 16732 and 37695 on January 30th, 2017

1) Sprinkler head missing escutcheon plate at Grant Building Floor number 8 - Hallway by Cont. Care Nursery.

2) Sprinkler head missing escutcheon plate at Grant Building Floor number 8 - Teen room.

3) Grant floors 1 through 8 all have closets entering the corridor/ smoke compartment that do not have sprinkler coverage.

The fire protection officer was present during this observation


**Based on observation of surveyors 16732 and 37695 on January 31, 2017

1) Sprinkler heads missing escutcheon plate at Grant Building Floor number 2 - volunteers office and both closets.

2) Sprinkler heads missing escutcheon plate at Grant Building Floor number 2 - skills learning lab.

3) Sprinkler heads missing escutcheon plate at Grant building Floor number 2 - alcove across from Food nutrition office.

4) Grant Building Floor number 2 volunteers office storage in closet within 18" of sprinkler head.

5) Sprinkler coverage missing in storage closed across from volunteer service office on Grant Building Floor number 2.

The maintenance engineer was present during this observation.

**Based on observation and record review of surveyor 37696 on January 30th and 31st:

1) Grant North/South waterflow alarm device covers are missing or removed. These must be put back in place to prevent false alarms.

2) Considerable rust present on exterior of piping riser Philips Oliver section.

3) Pavilion 2nd floor water fall feature has no sprinkler coverage inside of wall.

4) Rear hall in dialysis lacking proper fire sprinkler coverage.

5) A permanently marked metal or rigid plastic information sign shall be placed at the system control riser supplying an antifreeze loop, dry system, preaction system, or auxiliary system control valve. Each sign shall be secured with a corrosion-resistant wire, chain, or other acceptable means and shall indicate the following information:
(1) Location of the area served by the system
(2) Location of auxiliary drains and low-point drains
(3) The presence and location of antifreeze or other auxiliary systems

6) The use of sidewall type fire sprinklers throughout facility with waffle ceilings, sidewall sprinkler are to be used on smooth flat ceilings only.

7) 8th floor Pavilion missing coverage under ductwork more than 4' wide

8) Parking Garage dry pendant sprinklers that have been in service 10 years shall require testing and or replacement.

9) Kelly Building above dropped ceiling on floor 5 has sprinkler heads above the ceiling that were identified on June 17, 2010 by the
Office of State Fire Marshal and were required in a correspondence to the facility that they shall be replaced or representative samples from one or more samples area shall be tested. Test procedures were to be repeated at a 10-year intervals. Upon record review no documentation could be found that the heads have been tested.

It was observed by Inspector 37696 and Director of Construction Services for EMMC

1) that the following locations have missing or other issues with the Escutcheon rings.
Kegan 4: Life Flight Office - Men's locker room, Clinical Engineering Workshop,
Kegan 3: sub sterile room, in electrical closet CEPP-3N by Pre-op
PO 3: gap around escutcheon ring over the door to the right of the nurses station,
Kelley 5: stairwell has gap around escutcheon ring
Kegan 2: by Wound Clinic back door

2) that the following locations have sprinkler heads that are blocked
PO 3: shower curtain blocks the sprinkler head, stackable washer/dryer 12" from sprinkler head,
Kelley 5: staff from across from dining/activity room, items stored on top shelf too close to sprinkler head,
Haskell 3: top shelf in housekeeping closet @ the roan end of the corridor is 16" from sprinkler head
Haskell 2: storage on top shelf of walk through closet stacked too high
Kelley 3 Storage Room 08 with washer/dryer, the metal lockers are 16" from the sprinkler head

3) the manual pull station for the Intergen extinguishing system at the door between the mechanical room & IT was in accessible due to items being stacked/stored in front of it.

Based on observation of the surveyor 35163 and 37694 on 1/30/17, in the presence of the maintenance manager the following was not met:

1. Alcove located across from room #683 (level 6 Penobscot building) had a large amount of combustible storage and was open to the corridor with no door.

Based on observation of the surveyor 35163 and 37694 on 1/30/17, in the presence of the maintenance manager the following was not met:

1. Tel/Data room located near nursing station in the penobscot building level 7, had penetrations that would not prevent the passage of smoke.

2. Laundry room located in the family room of level 7 of the penobscot building had gaps around dryer exhaust duct that would not prevent the passage of smoke.

3. Electrical room located near registration in the grant building, had missing sheetrock/open ceiling that would not prevent the passage of smoke.

4. Grant 1 building, utility room (ICU-164C) located in the family room had plywood that did not have any stamp to indicate that it was flame retardant and room has penetrations that would not prevent the passage of smoke.

5. Oxygen storage room in ICU (ICU) had penetrations above the electrical panels that would not prevent the passage of smoke.

Based on observation of the surveyor 35163 and 37694 on 1/31/17, in the presence of the maintenance manager the following was not met:

1. Data room cardiology housekeeping closet had penetrations that would not prevent the passage of smoke.












37694

While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.Pipe penetration in ceiling outside Surgical Patient Reception entrance shall be sealed.

Between 1-30-2017 and 1-31-2017 while surveying this facility with a facilities representative and surveyor 37696 this surveyor did observe:

3rd floor Keagan Building -Sprinkler room door would not close and latch.

Phillips Building - 3rd floor: closet door located near room 394 shall close and latch.

Haskell Building 1st floor: the kitchen area door shall self-close and positively latch at all times.





37696

It was observed by Inspector 37696 and Director of Construction Services for EMMC
1) that the following areas had corridor doors block or propped open:
PO 3 door between the locker room and nurses station could not be closed due to chairs and stored wet floor signs blocking the door swing
Haskell 2 Directors Door propped open with a trash can

2) PO3 Rm 388 top of door, handle side, gap to frame is larger than allowable 1/2"









35163


Based on observation of the surveyor 35163 and 37694 on 1/30/17, in the presence of the maintenance manager the following was not met:

1. Patient room door # 590 (sliding door) would not properly latch when close. This room is located in the penobscot building level 5.

2. Patient room door # 575 (sliding door) would not properly close/latch. It appears door is binding on guide rail.
This room is located in the penobscot building level 5.

3. Grant 1 building-Closson ICU/old ICU double doors at entrance had gap larger than 1/8" between doors and would not prevent the passage of smoke.

4. Trauma room 1 located in the ER would not properly latch. The small leaf of the double door had a latch that would not properly function and allowed both doors to be open when a small amount of force was applied to the door-not using the latch release on the door.

5. Doors located in the endoscopy and cath lab areas had electronic latches that did not keep doors latched (they were not engaged/activated). I was advised by the staff that the door latches are activated at a scheduled time each evening and could be release with badge access and would also release upon fire alarm activation. No documentation was provided to indicate that the latches engaged/activated when the fire alarm was activated.






37694

While inspecting this facility on January 30th, 2017 with the Facilities Manager and surveyor 35163, this surveyor did observe:
1.The Housekeeping closet door next to the Developmental Storage Room on Penobscot 7 was propped open with wedge. There shall be no impediments to the closing of corridor doors.

2.Self-closing hardware shall be installed on door to the data closet in the ICU.

3.Door to the Soiled Utility room in CCU shall positively latch.

4.There is a ¾" gap on first set of smoke barrier doors on the right into the staff locker room on Grant 1.
5.Kickstop shall be removed from Radiology entrance door in CCU corridor. There shall be no impediments to the closing of corridor doors

While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.The Soiled Utility room in the Cath Lab shall be adjusted to positively latch.

2.The EP Lab 1 corridor door shall be adjusted to self-close.

3.Self-closing hardware shall be installed on the Soiled Utility room in EP Lab 2.
4.EP Lab 2 door from the storage room to the corridor shall be adjusted to self-close.
5.The Endoscopy Treatment 3 door shall positively latch.

6.There is a ¾" door gap on door 1202 to Procedure Room 2 at the end of the hall.
7.Radiology Data Room door next to the locker room shall be adjusted to self-close.

8.Radiology badge access door from Medical Imaging shall be adjusted to self-close.

9.The Family Conference Room door in OR Intake open was being propped open with a wedge. There shall be no impediments to the closing of corridor doors.

10.Trauma 2 door shall be adjusted to self-close. It currently will not shut because it is binding on the secondary leaf latch.

11.The Alcove E door in the ED shall positively latch.

12.Soiled Utility door by Room 5 in the ED shall positively latch.

13.Storage room across from the RMS door shall be adjusted to self-close.
14.GRT -0-BOC-38 Biohazard room door shall positively latch.
15.Self-closing hardware shall be installed on both doors to the Perfusion Storage Room to OR 10.
16.Self-closing hardware shall be installed on corridor door to Sub-sterile Room to OR 10.










16732

Based on observation of surveyors 16732 and 37695 on January 30, 2017

1) Grant Building Floor number 8 - Room number 106 B door does not close and positively latch as hitting on frame.

2) Grant Building Floor number 8 - Room number 875 has small leaf that does not latch.

3) Grant Building Floor number 6 - Room number 634 is a storage room and door is not self closing.

4) Grant Building Floor number 6 - Room number 631 is a storage room and door is not self closing.

5) Grant Building Floor number 6 - Room 627, door does not latch on closing.

6 ) Grant Building Floor number 5 - Room 618, door does not latch on closing.

7) Grant Building Floor number 5 - Room numbers 501 and 502 blocked from closing with solid linen carts.

8) Grant Building Floor number 5 - Room number 505 does not latch on closing.

9) Grant Building Floor number 5 - Room number 535 has a gap greater than 1/2 of an inch while latched.

10) Grant Building Floor number 4 - Room number 415 has garbage can holding door open.

11) Grant Building Floor number 4 - Door to GRTT 103 does not latch closed.

12) Grant Building Floor number 4 - Room number 436 door does not latch close.

13) Grant Building Floor number 3 - Room number 320 does not latch close.


The fire protection officer was present during these observations

Based on observation of surveyors 16732 and 37695 on January 31, 2017:

1) Grant Building Floor number 2 - skills learning lab door propped open with trash can.

The maintenance engineer was present during this observation

On 1-30-2017 During our inspection Surveyors 16776/ 36433 and Maintenance Director observed Holes and penetrations in the
Rated Walls and Ceiling. Listed below will be the Locations related to this K-Tag.

Blasisdell P.O. building:

Level 1;

1. Ceiling and wall Hole penetrations in the location of the Print Shop to the Mail-Room.

2. Hole penetrations in Wall by the High Voltage Room in the corridor.

3. In the corridor by the Crome Room sprinker pipe's penetrations into the 2 hour rated wall.

________________________________________________________________________________

Level # 5: Blaisdell P.O.

4. At At Fire door F-551 Holes penetrations in Blockwall.

5. Penetrations in Smoke wall at F-551A.

6. By Exam Room # 5 Penetrations in walls ( Note this area was not found on the floor plans and I.D. as a Smoke Partition.).

________________________________________________________________________________

Level #3 (C) Blaisdell P.O.

7. Housekeeping Room penetrations in wall need to be sealed.

8. In Kitchen I.D. as P.O. 3 penetrations to the walls and ceiling need to be sealed off. ( all in a smoke barrier).

9. In Office by the eye wash station penetrations to 2hr rated wall.

10. P.O.3 the 247 Computer Room penetrations to wall 2hr rated.

11. On Level 3 P.O. Egress Stair F-331: Requires rated walls between adjacent office and stair Missing Drywall on the rated wall system office side.

________________________________________________________________________________

Floor # 2 P.O.

12. Penetrations Holes at the Exit door Stairs at Phillips Oliver Elevator Stairs.

13. Same Location as above Ceiling penetrations from pipe chase to Flooe # 2. need to be sealed.

14. P.O.1 Elevator Room, (Rated room) Penetrations Holes need to be filled in.

15. Location accross from the Cath-Lab by the Electrial Panel Penetrations to smoke wall need to be sealed off.

16. In the Hallway from the break Room to the Cath -Lab Penetrations to the (smoke rated) walls and ceiling to be sealed off.

________________________________________________________________________________

On 1-31-2017 During our Inspection Surveyors 16776 / 36433 / 38667 and Maintenance Director Observed Holes and Penetrations in the Rated Wall's and Ceiling. Listed Below will be the locations related to this K-Tag.





Grant Building:

1. Grant Stair south Level 2; Penetrations to the wall , electrical box in pipe chase not sealed.

2. Grant Stair South level 6 ; Standpipe Box lining is loose from the sheetrock and need to be repaired to maintain 2hr rating.

3. Grant building Level 6 ; Shaft by Soiled utility room penetrations to wall from cast iron pipe, above the ceiling.

4. Grant building level 6 ; By doors GRT-6-S654A has penetrations at and around the data cables that need to be cut out and sealed properly.

5. Grant Building Level 6 ; Hallway corridor smoke barrier has cast iron penetrations that are not sealed above the ceiling.

6. Grant Building Level 6; Data Room multiple penetrations not sealed in the ceiling area not smoke tight.

7. Grant Building Level 4; At GRT4-S435B has Ductwork penetrations that need sealing through the wall.

8. Grant Building level 4; By the staff room has penetrations above the ceiling that are not sealed at the heat pipe and conduit penetrations above door # GRT4-RM-441.

9. Grant Building Level 4; Wall by Door GRT4-RM442 data cable penetrations are not sealed.

10. Grant Building level 3; Smoke barrier above doors GRT3-N3-FDH2 has data cable penetration sleeve that not sealed properly.

11. Grant Building level 3; Smoke partition by north stairwell at the staff lounge has penetrations that need to be sealed.

12. Grant Building level 0 ; At 3hour wall at the vendor room door area has penetrations above the double doors by FEC PNBO-FEX-5 and vendor room that need sealing.

13. Grant level 0; At 1 hour wall above vendors room door has 3 fire alarm box penetrations that need to be sealed above FEX-PNBO-FEX5.

14. Grant Level 0 ; Mechanical AHU 1,2,3 has styrofoam on the ceiling in the mechanical roomthat must be removed and sealed if necessary.

15. Grant Building level 0; Above door AHU123-GD-001 has penetrations through the wall that need to be sealed.

16. Grant Building level 0 ; Mechanical room AHU4 above door HSR17A has penetrations through the wall that need to be sealed.


17. 3 hour wall at demising wall connector between the Weber building and the Penobscot Pavilion at PNB1-Exit - 13 has a green armored cable penetrations that need to be sealed.

It was observed by Inspector 37696 and Director of Construction Services for EMMC the smoke doors in the following locations did not operate properly
1) smoke door in Grant Connector by Kelley 3 do not close completely due to air pressure on one side of the door. "Breeze" holds the door open. Additionally, same door, the gap below the door sweep and the floor exceed 1-1/8"'

2) Smoke doors by BMAP Office the door leaf towards Grant does not close completely and appears to bind up on something







37694

While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.Smoke door between the Cardio and Cath Lab office shall be adjusted to self-close. It is currently catching on the bottom of the frame.

2.Right smoke barrier door GR1-N3-FDH-39 in x-ray corridor shall be adjusted to positively latch.
3. Smoke barrier door GR1-N3-FDH-27 at female lockers shall be adjusted to self-close.
4.Smoke barrier doors GR1-N3-FDH-9 by Operations Supervisor ' s Office and CRNA Lounge shall be adjusted to self-close.
5. Smoke barrier door GRT-1-73 shall be adjusted to self-close.
6. Smoke barrier doors GRT 1 - N3-FDH-25 by ED shall be adjusted to self-close.
7.There is a gap of 3/4" on the smoke barrier doors between Main OR and PACU.
8.There is a gap of 3/4" on the smoke barrier doors between Kagan OR and PACU.

It was observed by Inspector 37696 and Director of Construction Services for EMMC that the clothes dryer in Kelley 3 Room 08 has not been maintained per 4.6.13. Behind the dryer was built up with excessive amounts of lint and is was not connected to a vent.

Between 1-30-2017 and 1-31-2017 while surveying this facility with a facilities representative and surveyor 37696 this surveyor did observe:

3rd floor Keagan: Painting located near waiting area required to be flame retardant.

3rd floor Keagan near Endo : Cork Boards required to be flame retardant.



37694

While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.Plexiglas shall not be used as a decoration covering in the Cardio corridor.
2.Newspapers hung on a bulletin board outside CT nurse's office shall be covered with a fire resistant material.

Based on observation of the surveyor 35163 and 37694 on 1/31/17, in the presence of the maintenance manager the following was not met:

1. Back corridor between IR/CT (Grant 1 building) there was a trash container/cart larger than 32 gallons being stored in the corridor.



37694

While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.Soiled linen carts shall not be stored in the corridor. 2 soiled linen carts are currently being stored in the x-ray lobby locker area.
2.Soiled linen cart stored in corridor outside Room 4 of Breast and Osteoporosis Center.

It was observed by Inspector 37696 and Director of Construction Services for EMMC that electrical panel access was not kept clear or blocked in the following areas.
Kelley 3 Room 08 with washer/dryer. There were staff jackets piled on boxes stacked in front of the electrical panels
Life Flight corridor to flight deck - panel blocked by two large compressed gases tanks & trash can




37694

While inspecting this facility on January 30th, 2017 with the Facilities Manager and surveyor 35163, this surveyor did observe:
1.Maintain 3ft of clearance around the electrical panel in the electrical room by Registration on Grant 1. Housekeeping cart is currently being stored there.

While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.Maintain 3ft of clearance around the electrical panel in the EP Lab 2 x-ray generator room.

2.Electrical wiring in right electrical closet outside Surgical Patient Reception entrance required junction box.

3.Maintain 3ft of clearance around the electrical panel in the Equipment Room of OR 12.





16732

Based on observation of surveyors 16732 and 37695 on January 30, 2017

1) Grant Building Floor number 5 - Room GRTS-5-5-133 has electrical panel missing cover.





Based on observation of surveyors 16732 and 37695 on January 31, 2017

1) Mechanical room AHU6 has garbage can within 3 feet of electrical panel

2) Grant Building Floor number 2 - Room number AHU23 has storage within 3 feet of electrical panel.

3) Grant Building Floor number 2 - Red bag waste room has open electrical wires on ceiling, box needs to be covered.

Based on observation of the surveyor 35163 and 37694 on 1/31/17, in the presence of the maintenance manager the following was not met:

1. Cath lab office had interconnected multi outlet device.

2. The charge reconciliation coordinator office had interconnected multi outlet devices.

3. Dialysis clean utility room had a extension cord being used to power permanent equipment.



37694

While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.Power strips shall not be used as a constant source of power. Interconnected power strips were being used under the Cath Lab Nurse's desk.
2.Power strip shall not be used as a constant source of power. Power strip being used in the EP Lab 1.





16732

Based on observation of surveyors 16732 and 37695 on January 31, 2017

1) Grant Building Floor number 2 - Patient Relations office had Fridge, Microwave, and Keurig plugged into power strip.

2) Grant Building Floor number 2 - Mason Cafeteria, Salad bar compressor is being powered by extension extended down from ceiling and plugged into another extension cord into cabinet under salad bar. The second extension cord is then wired into a junction box.

3) Grant Building Floor number 2 - Pharmacy room as two laboratory refrigerators plugged into power strip.

The maintenance engineer was present during these observations

Between 1-30-2017 and 1-31-2017 while surveying this facility with a facilities representative and surveyor 37696 this surveyor did observe:


Haskell Building floor # 1 oxygen room requires a precautionary sign.


Haskell Building #2 Clean utility room with oxygen stored inside requires a precautionary sign.



37696

It was observed by Inspector 37696 and Director of Construction Services for EMMC that the following areas have O2 being stored without required signage
Kelley 3 Clean linen
Kelley 3 Soiled linen
Kelley 2 PFT Lab
PO 5 gym closet







35163

Based on observation of the surveyor 35163 and 37694 on 1/30/17, in the presence of the maintenance manager the following was not met:

1. Clean supply room in penobscot building level 7, had oxygen storage in excess of 300 cu ft and was not labeled as a oxygen storage room.

2. Clean supply room in penobscot building level 6, had oxygen storage in excess of 300 cu ft and was not labeled as a oxygen storage room.



37694

While inspecting this facility on January 31st, 2017 with the Facilities Manager and Surveyor 35163, this surveyor did observe:
1.Signage required on the oxygen storage room for the 1st door in Cath Lab Recovery on the right.
2.Self-closing hardware shall be installed on the oxygen storage room in the Cath Lab.
3.Signage required on the oxygen storage room for the larger clean supply door in Endoscopy.





16732

Based on observation of surveyors 16732 and 37695 on January 31, 2017:

1) In the material management shop there were over 70 gas cylinders (mostly E cylinders) and aprox 9 H cylinders awaiting pickup from companies. The shop area is not a properly protected storage area for over 300 cubic feet of oxygen storage

The maintenance engineer was present during this observation

Between 1-30-2017 and 1-31-2017 while surveying this facility with a facilities representative and surveyor 37696 this surveyor did observe:

3rd floor Keagan building-Medical Gas room: Oxygen cylinders found unchained, or supported in a proper cylinder stand or cart.