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The facility failed to provide and maintain the HVAC duct dampers per code. Findings include:

During the survey, the following was observed on the First Floor:
1. The smoke barrier between the Risk Management Office and the Glass Corridor had two HVAC ducts close to the roof deck penetrating the smoke barrier that did not have smoke dampers or access panels.
2. The two hour fire barrier at the Janitor's Storage - above door #0552 had two HVAC ducts penetrating this barrier that did not have access panels; could not verify if there was a fire damper in them.
3. The HVAC ducts penetrating the two hour fire barrier at fire door #0553 did not have fire dampers.

1999 NFPA 90A, 2-3.4.1 A service opening shall 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.

1999 NFPA 90A, 3-3.1.1*
Approved fire dampers shall 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.
Exception*: Fire dampers shall not be required where other openings through the wall are not required to be protected.

1999 NFPA 90A, 3-3.1.2
Approved fire dampers shall 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.

1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closer to the smoke barrier.

1999 NFPA 90A, 3-4.5.4 Dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.


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The facility failed to maintain/provide a smoke venting system per code. Findings include:

During the survey, the following was observed:
2. Per interview the Old O.R. 2 did not have a smoke venting system.

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."

1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).