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HAMILTON MEMORIAL HOSPITAL
No Description Available
Tag No.: K0024
Based on document review of plans and based on discussions with the Facilities representative the surveyor finds that designated smoke compartments do not comply with 18.3.7.1. Failure to identify and maintain required smoke barriers could allow smoke to spread beyond the compartment of fire origin.
Findings include:
A. 08/21/2014 at 11:00am Due to the lack of indicated smoke barriers on the Facility provided Life Safety Plans it appears that the travel distance from one smoke compartment to the next exceeds the allowable maximum distance to comply with 18.3.7.1 (4).
1. It appears that PT, Respiratory Therapy, Lab, X-ray, Boiler, Chiller, Generator and part of the 2010 Med/Surg addition are all located within one large smoke compartment. The Facility representative was unable to identify a smoke barrier within this area to comply with 18.3.7.1. Therefore, this area is a noncompliant smoke compartment due to the following:
a. A smoke compartment is required to divide every story having an occupant load of 50 or more persons into not less than two compartments to comply with 18.3.7.1 (2).
B. 08/21/2014 at 11:00am The facility representative was not able to identify the square footage of any smoke compartment within the facility to comply with the size limit in accordance with 18.3.7.1(3).
No Description Available
Tag No.: K0130
Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.
Findings include:
A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.
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