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Fire separation barriers are not maintained in accordance with 19.1.2.3 and 8.2.3. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the different occupancies.

Findings include:

A. CORRECTED 01/29/13

B. On 7/25/12 at approximately 3:15pm, the Ground floor 2-hour barrier doors between the Hospital Building "B" corridor and the adjacent Business Building "C" corridor were observed to not be positive latching upon closing to comply with 8.2.3.2.1.
UPDATE 01/29/13 The doors remain non-complaint.

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA 13-1999 and NFPA 25-1998. This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

A. CORRECTED 01/28/13

B. CORRECTED 01/28/13

C. CORRECTED 01/28/13

D. CORRECTED 01/28/13

E. On 7/24/12 at approximately 2:00pm, it was observed during document review of the quarterly sprinkler system inspections that no documentation that the fire pump was run on emergency power was available to comply with NFPA 25-1998, 5-3.3.4.
UPDATE 01/29/13 This tag item remains open. The facility is in the process of completing the work involved.

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.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA 99-1999 and NFPA 70-1999, 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:

A. During the survey walk-through on 7/25/12, it was observed that electrical panels throughout the building did not appear to be separated into Life Safety panels, Critical panels, and Equipment panels. The following observations could not confirm that the loads specifically allowed to be on each of the branch panels was in compliance with NFPA 99-1999, 3-4.2.2.2 and NFPA 70-1999, Section 517.

1. At approximately 10:30am, panels in the 4th floor ICU appeared to be originally labeled "C4-A" and later also tagged with a "Life Safety" label. The "C4-A" designation appeared to indicate the panel to be a "Critical branch" panel and not a "Life Safety branch" panel because it was serving circuits assigned to receptacles, .

2. At approximately 1:40pm, the "C2-A" panel at the 2nd floor Electrical panel room at the cross corridor north of the nurse station was observed to have four circuits (23, 25, 27, 29) labeled as serving the fire alarm system. This panel was also labeled as a "Life Safety" panel but had other circuits which appeared not be be permitted to be on a "Life Safety" branch panel.

3. At approximately 2:45pm, the "CG-A" panel at the Ground floor Emergency room was observed to also be tagged with a "Life Safety" label. This panel included circuits labeled as serving "exhaust fans", "fridge", "roll-up door". The "LG-C" panel was also tagged with a "Life Safety" label and included circuits labeled as serving "lights", "receptacles", "air curtain".

UPDATE 01/29/13 Surveyor observed progress on K-Tag items 1 -3.