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Base on random observation during the survey walk-through on the morning of August 2, 2011, the surveyors accompanied by the facility engineer finds that corridor doors do not resist the passage of smoke to comply with 18.3.6.3.
This deficient practice could affect patients, visitors and staff within the Hospital's exit access corridors if a fire were allowed to spread from an area or room into the corridor.

Finding includes:

A). Second floor, Exam room used for Physical Therapy and Staff Lounge located adjacent to elevators which due to the placement of door wedges allowed these rooms (which were not occupied at the time of observation) to be open to the corridor and does not comply with 18.3.6.3.3 for the type of allowable hold open device.




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Base on random observation during the survey walk-through on August 2, 2011, the surveyors accompanied by the facility engineer observed that not all fire resistive assemblies are constructed or maintained to comply with 8.2.3.2.4.2. This deficient practice affects the patients, staff and visitors on two floor levels and within two smoke compartments by allowing smoke and fire from one floor level to affect individuals on the floor above.

The findings include:

A). Second floor I.T. room, a designated 2-hour fire rated floor construction (Building Construction Type I -NFPA 220) was observed which lacked protection due to a conduit penetration which does not maintain the floor's fire resistant rating, does not maintain the floor as a separating smoke barrier and allows for a unprotected vertical opening between floors.




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Based on random observation during the survey walk through on the afternoon of August 2, 2011 the surveyors accompanied by the facility engineer, observed that not all fire resistant rated smoke barriers appear to form a complete barrier to comply with 18.3.7.3. This deficient practice could affect the patients, staff and visitors in two adjacent smoke compartments by not providing a complete separation.

The finding includes:

A). First floor, Kitchen servery smoke barrier wall as shown on the Life Safety floor plans does not match what is constructed. Therefore the termination to an outside wall for the smoke barrier on the first floor is unknown which does not comply with 8.3.2.




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Base on random observation during the survey walk-through on the afternoon of August 2, 2011, the surveyors accompanied by the facility engineer observed that areas are being used for storage of combustible materials which do not meet the requirements for hazardous enclosures to comply with 18.3.2.1.. This deficient practice which lacks separation of a hazardous area from an exit access corridor could affect patients, staff and visitors within one smoke compartment during a fire emergency.

Finding includes:

A). First floor, Lab, Reception room is being used for the storage of paper products and combustible materials. This room lacks separation from the exit access corridor due to the following:

1. A glazed sliding pass through window.

2. Entry door is not self-closing to comply with 18.3.2.1. and 8.2.3.2.3.1.(2).




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Base on random observation during the survey walk-through on the afternoon of August 2, 2011, the surveyors accompanied by the facility engineer observed that the exit discharge to a public way does not comply with 7.1.6.2 for a change in elevation. This deficient practice which does not provide for unobstructed travel from an exit access corridor could affect patients, staff and visitors within one smoke compartment during a fire emergency.

Finding includes:

A). First floor, exit discharge from the Surgery suite contains a step off which does not comply with 7.1.6.2 for a change in elevation to the side walk. Further, the physical condition of the sidewalk itself allows for a tripping hazard.




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Base on random observation during the survey walk through conducted on the afternoon of August 2, 2011, the surveyor and the facility engineer observed a designated 2-hour fire rated separation that does not form a complete barrier to comply with 7.2.1.8.1. and 8.2.2.2 due to the following:

The finding includes:

A) First floor entry door to Physical Therapy is held open with a wooden door wedge.




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Based on document review conducted on August 1, 2011 with the facility engineer, it was noted that written records for fire drills are not being maintained and that fire response drills are conducted to comply with 18.7.1. This deficient practice could affect the safe and reliable movement to an area of refuge for all patients, staff and visitors within the Hospital and the MOB during a fire emergency.

Findings include:

A) The most current fire drill was conducted in July. The document consisted of the log for time, date and included the staff who participated. The provided documentation lacked information pertaining to the following:

1. Location and type of device used to test the fire alarm system.

2. There was no information confirming that the Main Fire Alarm Control Panel was monitored to determine that it functioned properly.

3. The surveyor could not confirm from on site documentation, that fire drills are conducted, using a variety of devices and that all health care personnel shall be instructed in the use of a code phrase to ensure transmission of an alarm to comply with 18.7.2.3 (1) and (2).




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Based on random observation during the survey walk on the afternoon of August 2, 2011 the surveyors accompanied by the facility engineer observed that not all exits contain a manually operated fire alarm box to comply with 9.6.2.3. This deficient practice could affect staff visitors and patients from quickly notifying the facility of an emergency within the hospital and the MOB.

The finding includes:

A).. The fire barrier separation between the MOB and the Hospital on the First and Second floors. The designated exit at the pair of cross corridor doors (as shown by the exit sign located above the doors) for the barrier lack manually operated pull stations.
Locations observed:

1. Second floor, the MOB side of the pair of barrier doors

2. First floor, the Hospital side and the MOB side of the barrier doors




.

Base on random observation during the survey walk-through on the morning of August 2, 2011, the surveyors accompanied by the facility engineer observed that 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 18.2.3.3. This deficient practice could impact patients, staff and visitors on the second floor from reaching an exit stair.

Findings include:

A). Second floor, Patient corridors contain nurse charting stations having chairs within the exit access corridors. This produces obstructions within an exit access corridor and does not comply with 18.2.3.3. and 7.1.10.2.2.




.

Base on random observation during the survey walk-through on the morning of August 2, 2011, the surveyors accompanied by the facility engineer observed that not all portable medical gases are stored in accordance with NFPA 99. This deficient practice could impact the safety of patients, staff and visitors within one smoke compartment due to the lack of proper separation of combustible materials.

Findings include:

A). This same item was cited in a previous survey. Medical gas tanks were observed being stored that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2.c.2. Location observed:

1. Second floor Clean Utility, 5 tanks.




.

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). The facility is constructed with a two story atrium which has an engineered smoke management system. Through Staff interview it was determined that semi-annual testing of this smoke management system has not been conducted as required by NFPA 92B, or that fire alarm components for sequential control of this system are tested to verify safe operation. Failure of this system to activate and operate as designed, could cause products of combustion to collect below the tenable level for the safe egress and evacuation of occupants should a smoke event occur.


20224


B). 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.


C). The CAH is constructed, arranged, and maintained to ensure access to and the safety of patients ...The premises are clean and orderly. The Critical Access Hospital (CAH) and its staff are not in compliance with applicable Federal, State and local laws and regulations to comply with CMS Regulation 485.608 (a) C-150 and the Illinois Hospital Licensing Act 250.2460 h) 5). due to the following:

1. Based on random observation during the survey walk through on August 2, 2011, the surveyors accompanied by the facility engineer observed the ceiling in both O.R.s which contained access panels that did not maintain the monolithic ceiling surface. Gaps along the perimeter of the access panels do not maintain a seal against the interstitial space above. Cracks or perforations in these ceilings do not comply.

Base on random observation during the survey walk-through on the morning of August 2, 2011, the surveyors accompanied by the facility engineer finds that corridor doors do not resist the passage of smoke to comply with 18.3.6.3.
This deficient practice could affect patients, visitors and staff within the Hospital's exit access corridors if a fire were allowed to spread from an area or room into the corridor.

Finding includes:

A). Second floor, Exam room used for Physical Therapy and Staff Lounge located adjacent to elevators which due to the placement of door wedges allowed these rooms (which were not occupied at the time of observation) to be open to the corridor and does not comply with 18.3.6.3.3 for the type of allowable hold open device.




.

Base on random observation during the survey walk-through on August 2, 2011, the surveyors accompanied by the facility engineer observed that not all fire resistive assemblies are constructed or maintained to comply with 8.2.3.2.4.2. This deficient practice affects the patients, staff and visitors on two floor levels and within two smoke compartments by allowing smoke and fire from one floor level to affect individuals on the floor above.

The findings include:

A). Second floor I.T. room, a designated 2-hour fire rated floor construction (Building Construction Type I -NFPA 220) was observed which lacked protection due to a conduit penetration which does not maintain the floor's fire resistant rating, does not maintain the floor as a separating smoke barrier and allows for a unprotected vertical opening between floors.




.

Based on random observation during the survey walk through on the afternoon of August 2, 2011 the surveyors accompanied by the facility engineer, observed that not all fire resistant rated smoke barriers appear to form a complete barrier to comply with 18.3.7.3. This deficient practice could affect the patients, staff and visitors in two adjacent smoke compartments by not providing a complete separation.

The finding includes:

A). First floor, Kitchen servery smoke barrier wall as shown on the Life Safety floor plans does not match what is constructed. Therefore the termination to an outside wall for the smoke barrier on the first floor is unknown which does not comply with 8.3.2.




.

Base on random observation during the survey walk-through on the afternoon of August 2, 2011, the surveyors accompanied by the facility engineer observed that areas are being used for storage of combustible materials which do not meet the requirements for hazardous enclosures to comply with 18.3.2.1.. This deficient practice which lacks separation of a hazardous area from an exit access corridor could affect patients, staff and visitors within one smoke compartment during a fire emergency.

Finding includes:

A). First floor, Lab, Reception room is being used for the storage of paper products and combustible materials. This room lacks separation from the exit access corridor due to the following:

1. A glazed sliding pass through window.

2. Entry door is not self-closing to comply with 18.3.2.1. and 8.2.3.2.3.1.(2).




.

Base on random observation during the survey walk-through on the afternoon of August 2, 2011, the surveyors accompanied by the facility engineer observed that the exit discharge to a public way does not comply with 7.1.6.2 for a change in elevation. This deficient practice which does not provide for unobstructed travel from an exit access corridor could affect patients, staff and visitors within one smoke compartment during a fire emergency.

Finding includes:

A). First floor, exit discharge from the Surgery suite contains a step off which does not comply with 7.1.6.2 for a change in elevation to the side walk. Further, the physical condition of the sidewalk itself allows for a tripping hazard.




.

Base on random observation during the survey walk through conducted on the afternoon of August 2, 2011, the surveyor and the facility engineer observed a designated 2-hour fire rated separation that does not form a complete barrier to comply with 7.2.1.8.1. and 8.2.2.2 due to the following:

The finding includes:

A) First floor entry door to Physical Therapy is held open with a wooden door wedge.




.

Based on document review conducted on August 1, 2011 with the facility engineer, it was noted that written records for fire drills are not being maintained and that fire response drills are conducted to comply with 18.7.1. This deficient practice could affect the safe and reliable movement to an area of refuge for all patients, staff and visitors within the Hospital and the MOB during a fire emergency.

Findings include:

A) The most current fire drill was conducted in July. The document consisted of the log for time, date and included the staff who participated. The provided documentation lacked information pertaining to the following:

1. Location and type of device used to test the fire alarm system.

2. There was no information confirming that the Main Fire Alarm Control Panel was monitored to determine that it functioned properly.

3. The surveyor could not confirm from on site documentation, that fire drills are conducted, using a variety of devices and that all health care personnel shall be instructed in the use of a code phrase to ensure transmission of an alarm to comply with 18.7.2.3 (1) and (2).




.

Based on random observation during the survey walk on the afternoon of August 2, 2011 the surveyors accompanied by the facility engineer observed that not all exits contain a manually operated fire alarm box to comply with 9.6.2.3. This deficient practice could affect staff visitors and patients from quickly notifying the facility of an emergency within the hospital and the MOB.

The finding includes:

A).. The fire barrier separation between the MOB and the Hospital on the First and Second floors. The designated exit at the pair of cross corridor doors (as shown by the exit sign located above the doors) for the barrier lack manually operated pull stations.
Locations observed:

1. Second floor, the MOB side of the pair of barrier doors

2. First floor, the Hospital side and the MOB side of the barrier doors




.

Base on random observation during the survey walk-through on the morning of August 2, 2011, the surveyors accompanied by the facility engineer observed that 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 18.2.3.3. This deficient practice could impact patients, staff and visitors on the second floor from reaching an exit stair.

Findings include:

A). Second floor, Patient corridors contain nurse charting stations having chairs within the exit access corridors. This produces obstructions within an exit access corridor and does not comply with 18.2.3.3. and 7.1.10.2.2.




.

Base on random observation during the survey walk-through on the morning of August 2, 2011, the surveyors accompanied by the facility engineer observed that not all portable medical gases are stored in accordance with NFPA 99. This deficient practice could impact the safety of patients, staff and visitors within one smoke compartment due to the lack of proper separation of combustible materials.

Findings include:

A). This same item was cited in a previous survey. Medical gas tanks were observed being stored that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2.c.2. Location observed:

1. Second floor Clean Utility, 5 tanks.




.

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). The facility is constructed with a two story atrium which has an engineered smoke management system. Through Staff interview it was determined that semi-annual testing of this smoke management system has not been conducted as required by NFPA 92B, or that fire alarm components for sequential control of this system are tested to verify safe operation. Failure of this system to activate and operate as designed, could cause products of combustion to collect below the tenable level for the safe egress and evacuation of occupants should a smoke event occur.


20224


B). 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.


C). The CAH is constructed, arranged, and maintained to ensure access to and the safety of patients ...The premises are clean and orderly. The Critical Access Hospital (CAH) and its staff are not in compliance with applicable Federal, State and local laws and regulations to comply with CMS Regulation 485.608 (a) C-150 and the Illinois Hospital Licensing Act 250.2460 h) 5). due to the following:

1. Based on random observation during the survey walk through on August 2, 2011, the surveyors accompanied by the facility engineer observed the ceiling in both O.R.s which contained access panels that did not maintain the monolithic ceiling surface. Gaps along the perimeter of the access panels do not maintain a seal against the interstitial space above. Cracks or perforations in these ceilings do not comply.