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A. Based on random observation uses in corridors do not comply with the exceptions under 19.3.6.1 Exception #1(a). The surveyor observed patient care areas that are open to the exit access corridors. Example locations include:

1. 2002 addition Second floor Recovery, Day Surgery Prep and Stage I Recovery.

2. 1977 addition First floor, Radiology Department, numerous use spaces open to exit access corridors.

3. CORRECTED 02/10/2010


B. The Facility representative during staff interview was unable to verify that these areas constitute a suite to comply with 19.2.5.2. Other similar locations observed:

1. Pain Clinic, Physical Therapy, and Occupational therapy. These areas all contained habitable room locations which lacked an exit access door leading directly to an exit access corridor to comply with 19.2.5.1.

A. Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.
Doors in exit access corridors were observed that are not positive latching. Example locations include:

1. 1977 addition First floor Radiology Dept (not indicated as a suite) contains numerous doors which are not positive latching.


2. 1977 addition Ground floor Occupational Health (not indicated as a suite) contains several doors which are not positive latching due to defective hardware.


B. Corrected 9/15/2010.
C. 1. Corrected 9/15/2010.
2. Corrected 9/15/2010.
D. 1. Corrected 9/15/2010.
2. CORRECTED 02/09/2010
3. CORRECTED 02/09/2010.

A. CORRECTED 02/10/2010
1. CORRECTED 02/10/2010
a. CORRECTED 02/10/2010


B. CORRECTED 02/10/2010

1. CORRECTED 02/10/2010


C. Pipe penetration through 2 hour fire floors were observed throughout the facility which are not sealed with a U.L. listed design assembly to protect against the passage of fire to comply with 8.2.3.2.4.1. Example locations observed:

1. CORRECTED 02/09/2010
2. CORRECTED 09/15/2010

3. 1977 addition Ground floor Boiler room PVC pipe penetrates the 2-hour floor above.

4. CORRECTED 09/15/2010
5. CORRECTED 02/10/2010

A. CORRECTED 02/10/2010
1. CORRECTED 02/09/2010
2. CORRECTED 02/09/2010
3. CORRECTED 02/10/2010


B. CORRECTED 02/10/2010
1. CORRECTED 02/10/2010
2. CORRECTED 02/10/2010
3. CORRECTED 02/09/2010
4. CORRECTED 02/09/2010
C. 1. CORRECTED 02/09/2010
2. CORRECTED 09/15/2010
3. CORRECTED 09/15/2010

D. Materials were observed being stored in the mechanical room which does not comply with 19.3.2.1. Location observed:
1977 addition Fourth floor.

E. CORRECTED 02/10/2010
1. CORRECTED 02/10/2010
2. CORRECTED 02/10/2010
3. CORRECTED 02/10/2010
F. CORRECTED 02/09/2010

A. CORRECTED 02/10/2010

1. CORRECTED 02/10/2010



B. CORRECTED 02/10/2010

1. CORRECTED 02/09/2010



C Based upon random observation the surveyor finds that exits are not enclosed and maintained as protected path to a public way to comply with Chapter 7 of NFPA 101. Locations observed:

1. Stair #4 discharges at the First floor through a required exit passageway. This exit passageway is not identified on any facility plans as an exit passageway. This exit passageway does not comply with 7.1.3.2.2 due to the following:

a. Two elevators open into the exit passageway. The elevator doors are not smoke tight and do not maintain the protected enclosure of the exit passageway from the elevator shaft.

b. The passageway lacks a continuous protected path to an exit discharge in accordance with 7.7.1 or 7.7.2. This passageway appears incomplete and does not extend to the exterior of the building. Surveyor noted that the passageway terminates to another corridor which does discharges to the exterior. However, this corridor contains ductwork, piping and other systems which do not serve the corridor.

c. An unoccupied mechanical
room opens into the exit passageway which does not comply with 7.1.3.2.1 (d).

2. Stair #5 discharges at the First floor through a required exit passageway. This exit passageway is not identified on any facility plans as an exit passageway. This exit passageway does not comply with 7.1.3.2.2 due to the following:

a. The passageway lacks a continuous protected path to an exit discharge in accordance with 7.7.1 or 7.7.2. Surveyor noted that the passageway contains ductwork, piping and other systems which do not serve the passageway.

b. Numerous unoccupied rooms deemed hazardous open into the exit passageway which does not comply with 7.1.3.2.1 (d). The hazardous rooms are as follows - Generator room, Paint room, Linen chute room.



D. CORRECTED 02/09/2010

1. CORRECTED 02/09/2010

A. Based on random observation during the survey walk through not all corridors have two remote exits to comply with 19.2.5.5. Surveyor observed a corridor leading from the heliport to the exit stair and elevator passed through a mechanical room being used for storage. Corridor access through a hazardous area does not provide a compliant exit access path.

Location observed: 1977 Fourth floor mechanical room

A. Based on random observation during the survey walk-through, not all suites are constructed or configured in accordance with 19.2.5.
Location observed: The Second Floor Recovery Area(s), Day Surgery Recovery/Prep area were observed to house holding bays that are not separated from the exit access corridor. The unit is not indicated on the facility's Life Safety Master Plans as constituting a suite. Numerous patient care areas are not directly connected to an exit access corridor, however the facility's Life Safety Floor Plans do not indicate these areas as constituting suites. Example locations refer to K-Tag 017 for habitable rooms not directly connected to exit access corridors.

1. The unit constitutes a suite which is in excess of the area permitted by 19.2.5.7.

OR

2. The holding bays are open to an exit access corridor which does not comply with 19.3.6.1.

A. The surveyor finds that a fire barrier is not installed to comply with 8.2.1 (1) for construction type separations. There is a pair of cross corridor doors at the separation which contain U L Labels indicating that they are 1 1/2 hour fire rated doors and close upon activation of the fire alarm system. The connection of the elevated walkway to the facility does not comply with NFPA 80A 1996 and NFPA 221 5.1.1 (fire separations between buildings). due to the following:
Location observed: 1954 addition Third floor, Elevated walkway to the parking garage

1. The walkway is not sprinkler protected and appears to be Type II (000) construction. The facility construction type is Type I (332) sprinkler protected. The facility Life Safety floor plans do not indicate a continuous 2-hour barrier in this location.

2. 1954 addition Third floor, elevated bridge walkway: There is no additional protection provided for unprotected window openings which are less than 10'-0" clear distance surrounding the walkway.

A. The provider lacks a comprehensive Life Safety Code Master Plan for each floor. The information provided for this survey and was not accurate as a Life Safety Code Master Plan.

The plans provided with colored lines indicating life safety features:

1. Exit Passageways were not indicated, however, the facility representative stated that certain areas were indeed exit passageways, however, during the walk through they were found to be deficient.

2. Fire barriers are identified with a red line. What type of fire barriers is not clear. The fire ratings for these barriers are not identified. Some of the barriers are clearly combination fire/smoke barriers but they are not identified as such. Other barriers enclose, shafts, exits and/or hazardous areas; however, not enough information is provided to evaluate such locations for compliance.

3. Smoke barriers are not identified as such. The fire ratings for each smoke barrier are not identified.

4. The size and boundary of each smoke compartment is not identified on plan.

5. The provider has no information identifying the locations, size and boundaries of suites. Travel distances in suites could not be evaluated. All areas have been evaluated in this survey as if there are no suites and all areas have exit access corridors, until such time that accurate information is provided. The surveyors expect to find additional deficiencies (for corridors) if accurate information regarding suites is not provided.

The surveyor finds that the provider cannot comply with 19.1.1.3 without the information identified above.

A. Corrected 9/15/2010.

B. By direct observation the surveyor finds numerous smoke detectors located within 3 feet of supply air diffusers. (NFPA 72, 1999, 2-3.5.1).




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C. Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed to comply with 19.3.4. During a test of the facility fire alarm system the following was observed

1. CORRECTED 02/10/2010


2 CORRECTED 09/15/2010

A. Corrected 9/15/2010.
B. Corrected 9/15/2010.













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C. Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.
Surveyor noted through out the facility that ceiling tile has been removed, which compromises sprinkler coverage and does not comply with NFPA 13 1999 5-6.4.1.1. Example locations observed:

1. Corrected 9/15/2010.
2. Corrected 9/15/2010.
3. Corrected 9/15/2010.
4. Corrected 9/15/2010.

5. CORRECTED 02/09/2010

6. CORRECTED 02/09/2010

7. 1977 addition Ground floor Boiler room, contains multiple holes in the finished ceiling system compromising sprinkler coverage.


D. CORRECTED 02/10/2010

1. CORRECTED 02/09/2010

2. CORRECTED 02/10/2010


E. 1. Corrected 9/15/2010.
2. Corrected 9/15/2010.


3. CORRECTED 02/10/2010

4. CORRECTED 02/10/2010

5. CORRECTED 02/10/2010.

6. CORRECTED 02/10/2010

A. By document review and staff interview, evidence was not provided for the 4 year inspection and maintenance of fire and smoke dampers. NFPA 90A, 1999, 3-4.7

A. Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3.
The finding includes: Carts, beds, and mobile equipment were observed within designated exit access corridors that obstruct egress and does not comply with 19.2.3.3. Locations observed

1. 2002 addition Second floor Surgery (not a designated suite).

2. 2002 addition First floor E.D. (not a designated suite).

3. 2002 addition Ground floor east/west corridor between Chiller room and Central Sterile areas along with the corridor leading to the receiving area.


B Based on random observation the surveyor noted chairs and an end table which were located such that the path of egress within a non designated suite was diminished below the minimum required width. Location observed:

1. 1977 addition, Ground floor Physical therapy and Cardiac Rehab

A. By direct observation and staff interview the oxygen zone valve for ICU is supplied from the zone valve for the adjacent medical surgical nursing unit as prohibited by NFPA 99, 1999, 4-3.1.2.3 (d)


B. By direct observation the surveyor finds the facility failed to provide an intervening wall between the zone valves and the outlets they serve at the following locations:
(NFPA 99, 1999, 4-3.1.2.3 (d)

1. Emergency room triage stations

2. Stage 2 recovery - "Day Surgery" Bays 1 - 6



C. CORRECTED 02/10/2010



D. CORRECTED 02/09/2010



E. CORRECTED 02/10/2010

Based on direct observation and staff interview, the facility failed to provide:

A. Remote alarm annunciator for three of three emergency generators at a constantly attended work station. NFPA 99, 1999, 3-4.1.1.15 (b)

B. Remote manual emergency stop stations for three of three emergency generators.
(NFPA 110, 1999, 3-5.5.6)


C. Three required branches of the essential electrical system (life safety, critical & equipment) for the 1913 building and additions, 1939, 1957 & 1963. (Staff indicated there is one transfer switch for the from the generator located on the first floor of the 1957 addition, with a connected load less than 150 kVA)


D. Corrected 9/15/2010.
E. Corrected 9/15/2010.
F. CORRECTED 02/10/2010

A. By direct observation and staff interview it could not be determined the function and purpose of the fans installed in the ceilings of stairwell # 1 & # 2. These fans are activated by the fire alarm although dampers did not open allowing purpose to be demonstrated.
.


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B. Interim Life Safety Measures: 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.

A. By direct observation the surveyor finds all elevators are not provided with the required Firefighter's Service elevator recall.