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A) Based upon random observation throughout the Hospital, based on document review and/or the lack of documentation and based on personnel interview of the Regional Director of Facilities and the Manager of Facilities, the surveyor finds that portions of the Hospital are Type II (000) Construction, as defined by NFPA 220. The Hospital is a five story building that does not comply with the minimum construction type requirements of 19.1.6.2:

Finding include but are not limited to:

1) Corrected 03/19/14

a) Deleted 03/19/14

b) Portions of the building have steel structural members. Some of this structure is protected as a fire rated assembly with monolithic ceilings. UL numbers for these systems were not available. Portions of the Main Building have been fire proofed via a project that was not completed. U L Design Numbers for the systems used for this project were not submitted to the Department and were not available on site. Portions of the building have structural steel elements that are unprotected (see below).

c) Deleted 03/19/14

2) While portions of the 4th Floor have fire proofed steel above lay-in ceilings and/or monolithic ceilings protecting structural steel above. The north end of the 4th Floor corridor up to the four hour vestibule was observed, with the Manager of Facilities present to be unprotected steel structural elements above a lay-in ceiling. This observation constitutes Type II (000) Construction. Roughly 40' of the north end of this corridor was not sprinklered in an otherwise sprinklered fire compartment.

a) Deleted 03/19/14

3) Corrected 03/19/14

a) Corrected 03/19/14

4) Corrected 06/06/13.

5) Corrected 10/22/2014.

Failure to install and maintain fire rated structural assemblies could result in a failure of the building structure during a fire.

A) Based on observation and based upon the lack of documentation, the surveyor finds that vertical openings are not protected in accordance with 8.2. of NFPA 101 - 2000 and/or NFPA 90A - 1999.

Findings include:

1) Corrected 10/22/2014

2) Corrected 10/22/2014

a) Corrected 06/06/13.

b) Corrected 03/19/14

c) Corrected 05/23/14

d) Corrected 05/23/14

e) Corrected 05/23/14

3) Corrected 06/06/13.

4) Corrected 10/22/2014

5) The Patient Rooms on the 4th Floor of the Southwest Wing are typical of many rooms on many floors (but not all rooms) for the southern portion of the building.

a) The patient room window walls have induction units that are not installed in accordance with NFPA 90A - 1975.

i) The vertical risers for the induction units are not enclosed as fire rated shafts from deck to deck. Fire ratings for the shaft enclosures were not available and the shaft terminate above the ceilings.

i) The duct feeds from the vertical risers into the induction units are 3" to 4" in diameter. The provider was not able to demonstrate that this duct feeds at sealed at the shaft enclosure in accordance with the original design requirements from NFPA 90A. Almost every room if not all rooms were patient occupied - access for inspection was extremely limited.

b) Although some of the patient rooms have bathroom exhaust duct runs that extend to shafts with fire dampers, a number of rooms typically at the end of the Southeast and Southwest wings have vertically exhaust ducts that extend to the room, that are not enclosure in fire rate shaft enclosures and that also lack fire dampers where the ducts penetrate required shaft enclosures.

c) Similar conditions to those cited above were observed in the 2nd Floor South Wing patient rooms.

d) Based on observation on two patient floors. Based upon the limited information available from the provider and based upon very limited access to patient rooms for inspection, the surveyors find that the patient rooms on the 3rd and 5th Floor as similar or the same as those observed on the 4th and 2nd Floors and the same deficiencies are expected as those cited under "a" and "b" above.

6) Corrected 10/22/2014

7) Corrected 06/03/15

a) Correced 06/03/15

b) Corrected 10/22/2014

8) Corrected 06/03/15

a) Corrected 06/06/13.

b) Corrected 06/03/15

9) Corrected 06/03/15

10) Corrected 10/22/2014

11) Corrected 10/22/2014

Failure to provide and maintain fire rated shaft enclosures and fire dampers at shaft penetrations will allow fire to spread from floor to floor in a fire emergency.

Based on observation, the surveyor finds that exit access corridors are obstructed. This condition will delay patient evacuation in a fire emergency.

Findings include:

1. At 11:00AM, on June 3, 2015 with the Manger of Facilities present, the surveyor observed that all of the corridor walls in the surgical cardiac area have signs indicating no storage. However, the one wall with no sign near Exit Stair # 14 was obstructed by seven carts and two sets of rolling steps. The exit access corridor was not maintain free and unobstructed in accordance with 7.3.4.1.


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B. Corrected 06/03/15

Based observation during the survey walk-through, and document review, the surveyor finds that the facility is not in compliance with a the Life Safety and failed to implement adequate interim life safety measures

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

The provider failed to implement and maintained adequate interim life safety measures in accordance with 4.5.1 of NFPA 101-1999.

Examples include:

1. At 1045AM on June 3, 2015 with the Manager of Facilities present, the surveyor observed two 5th Floor construction projects where the floor were continuously covered with paper and the sprinkler system (and an detection devices) were compromised by missing ceiling throughout the project area. A review of the project documentation at 10:00PM, with the Manager of Facilities present, included interim measures which showed this project had been evaluated as fully sprinklered and the "sprinkler system was not obstructed." The fire watch implemented for this project was documented as once every eight hours. The risk assessment was not accurate, the sprinkler system was obstructed and the interim measures implemented were based on faulty information. The provider failed to perform an accurate risk assessment and failed to implement adequate interim life safety measures.

2. At 1145AM on June 3, 2015 with the Manager of Facilities present, the surveyor observed a 1st Floor construction projects where the ceiling had been completely removed (electrical project). Two of two sprinkler heads were secured to a wall and were not installed to protect the room. A room adjacent to this space had a missing ceiling tile. A review of the project documentation at 10:00PM, including any interim measures, showed that this project had been evaluated as fully sprinklered and the sprinkler system was not obstructed. The fire watch implemented for this project was documented as once every eight hours. The risk assessment was not accurate, the sprinkler system was obstructed and the interim measures implemented were based on faulty information. The provider failed to perform an accurate risk assessment and failed to implement adequate interim life safety measures.

3. The north side of the hospital has a crawl space and mechanical system tunnels which are underground. One of these tunnels is located under the sidewalk along the north side of the hospital and is supported by unprotected structural steel. This tunnel is also not sprinklered. As part pf the Plan of Correction, this north tunnel was previously separated from the rest of the hospital by two hour fire barriers. However, at 1:00PM, on June 3, 2015, with Manager of Facilities present, the surveyor observed that two or two fire rated access panels in the two hour fire barrier was propped open. The provider lacks adequate means to maintain this required fire barrier.


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Based on random observation during the survey walk-through while accompanied by the senior electrician and the coordinator of building operations , the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panels EP-4W-1, LP-3W-C, LP-3W-C2, LP621, CLP-2W-2, ER-CP1, 1R-LRP-CR-1B, and 1-CLR-3 had circuits feeding the fire alarm panels, med gas alarm panels, and elevator cab lighting (these items should be served from the life safety panel). This does not meet the requirements of NFPA-70, Section 517-32 and 33.

2. Life safety panel EMLP-4 is serving a cardiac monitor and panel EM-L11 is serving the operating rooms on the fifth floor, (should be served by the critical branch), which does not meet the requirements of NFPA-70, Section 517-32.

3. (New 03/20/14): Panel IR-LRP-CR-1B, Panel LP-3W-C2 and/or Panel IR-LRP- IB all have conflicting panels schedules and they have circuits marked as feeding fire alarm system. These panels are identified at Critical Branch Panels of emergency power. The fire alarm panels are not supplied from the Life Safety Branch in accordance with 517-32.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present, the surveyor observed that electrical installations, equipment and materials are not installed and maintained in accordance with NFPA 70 - 1999.

Findings include:

1) Access to electrical panels and switchgear is blocked; 36" of clear space and a clear path are not provided and maintained.

c) Corrected 10/22/2014

d) (Revised 06/03/15): 12:00PM, on June 3, with the Facilities Manager present the surveyor observed one electrical panel in the southeast corner of the room which could not be reached due to the quantity of items stored in front of it. 3'-0" of clear space in front of the panel was not maintained in accordance with NFPA 70.



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Based on random observation during the survey walk-through while accompanied by the senior electrician and the coordinator of building operations , the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Corrected 10/22/2014

2. Bonding of the piping for the medical gas system could not be located by staff as required by NFPA-70, Section 250-104(c). This could cause a potential difference between med gas piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

3. Corrected 03/19/14

By direct observation the afternoon of 12/18/12 in the company of the Coordinator of Building Operations, the surveyor finds that sprinkler protection is provided in the penthouse elevator machine room (located at the fifth floor level of Stair Tower No. 1) for the elevator identified in the machine room as Elevator No.1, however heat detectors are not provided or install within 2 feet of each sprinkler head for elevator shut down prior to the discharge of water as required by NFPA 72, 1999 3-9.4 & ANSI/ASME A17.1, 102.2, c, .3).

Based observation during the survey walk-through, and document review, the surveyor finds that the facility is not in compliance with a the Life Safety and failed to implement adequate interim life safety measures

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

The provider failed to implement and maintained adequate interim life safety measures in accordance with 4.5.1 of NFPA 101-1999.

Examples include:

1. At 1045AM on June 3, 2015 with the Manager of Facilities present, the surveyor observed two 5th Floor construction projects where the floor were continuously covered with paper and the sprinkler system (and an detection devices) were compromised by missing ceiling throughout the project area. A review of the project documentation at 10:00PM, with the Manager of Facilities present, included interim measures which showed this project had been evaluated as fully sprinklered and the "sprinkler system was not obstructed." The fire watch implemented for this project was documented as once every eight hours. The risk assessment was not accurate, the sprinkler system was obstructed and the interim measures implemented were based on faulty information. The provider failed to perform an accurate risk assessment and failed to implement adequate interim life safety measures.

2. At 1145AM on June 3, 2015 with the Manager of Facilities present, the surveyor observed a 1st Floor construction projects where the ceiling had been completely removed (electrical project). Two of two sprinkler heads were secured to a wall and were not installed to protect the room. A room adjacent to this space had a missing ceiling tile. A review of the project documentation at 10:00PM, including any interim measures, showed that this project had been evaluated as fully sprinklered and the sprinkler system was not obstructed. The fire watch implemented for this project was documented as once every eight hours. The risk assessment was not accurate, the sprinkler system was obstructed and the interim measures implemented were based on faulty information. The provider failed to perform an accurate risk assessment and failed to implement adequate interim life safety measures.

3. The north side of the hospital has a crawl space and mechanical system tunnels which are underground. One of these tunnels is located under the sidewalk along the north side of the hospital and is supported by unprotected structural steel. This tunnel is also not sprinklered. As part pf the Plan of Correction, this north tunnel was previously separated from the rest of the hospital by two hour fire barriers. However, at 1:00PM, on June 3, 2015, with Manager of Facilities present, the surveyor observed that two or two fire rated access panels in the two hour fire barrier was propped open. The provider lacks adequate means to maintain this required fire barrier.


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