HospitalInspections.org

A. From random observation, the surveyors finds that fire separations between the hospital and other occupancies are incomplete, Findings include:

1. Ground Floor. Receiving Department is open to a non compliant pre-engineered building addition containing unprotected steel members and insulated infill panels which appear to be Construction Type II, 000. A continous 2-hour fire rated separation is not present between the Hospital's Construction Type I (332) in order to comply with NFPA 220 and NFPA 101 19.1.6.3.

2. First Floor, Temporary Main Entry connection between the Hospital and the Medical Office Building (MOB). This is a one story connection with a construction type of unprotected steel and infill glass panels addition that appears to be Type II (000). The surveyor was informed that this area is a Business Occupancy, however, there is no continuous 2-hour separation between the Hospital construction type (I, 332) and this area to comply with 19.1.2.1. Refer to K-Tag 044 item A.2.

A. Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. Portions of the steel structure were observed that are not covered by fire proofing materials in accordance with the designated UL Design. Location observed, 7th floor at the 2 hour separation from the Psychiatric Unit, above the cross corridor doors.

A. From random observation, the surveyor finds that spaces open to corridors do not comply with the exceptions under 19.3.6.1:

Second Floor Endoscopy (Inpatient/Outpatient) has patient recovery/holding bays that are open to the adjacent corridor. This condition does not comply with 19.3.6.1. Based upon this, the surveyor finds that this space is very likely intended to be a health care suite (treatment suite). No information is provided that identifies this space as a suite (see K048). The size and boundaries of the suite are not clearly identified.

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. Findings include:

1. Corrected 08/10/11.

2. 2nd floor, Recovery contains cross corridor horizontal sliding doors, the first door is activated by a floor mat, the second door is activated from a wall plate. During the fire alarm test the 2nd door did not reset and remained open, which does not comply with 7.2.1.9.

Update 02/02/2012: Due to time constraint the surveyor was not able to activate the fire alarm to verify and confirm correction of the above tag.



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B. Based on random observation the surveyor finds that corridor doors through out the facility lack positive latching hardware to comply with 19.3.6.3.2. Example locations and conditions observed include the following:

1. 2nd Floor O. R. area, (facility life safety plans do not indicate this area to be a suite) the following corridor doors lack latching hardware to comply with 19.3.6.3.2

a. Corrected 02/02/2012

New 02/02/2012 - The other corridor door leading to OR #3 -Rm266 from the Scrub sinks area lack latching hardware to comply with 19.3.6.2.

aa. Corrected 02/02/2012
bb. Corrected 02/02/2012
cc. Corrected 02/02/2012

b. Corrected 08/10/11.
c. Corrected 08/10/11.

2. 2nd Floor ICU rooms, the doors leading from each room(horizontal sliding doors) to the adjacent corridor (facility life safety plans do not indicate this area to be a suite) lacks latching hardware.

3. Corrected 08/10/11.
4. Corrected 08/10/11.
C. 1. Corrected 08/10/11.
2. Corrected 08/10/11.
3. Corrected 08/10/11.

1. Corrected 02/02/2012
2. Corrected 02/02/2012

A. 1. a. Corrected 08/10/11.
b. Corrected 08/10/11.

2. Corrected 08/10/11.
3. Corrected 02/02/12.
B. Corrected 02/02/12.



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C. 1. Corrected 08/10/11.
2. Corrected 02/02/12.
3. Corrected 02/02/12.
D. 1. Corrected 02/02/12.
2. Corrected 02/02/12.
3. Corrected 08/10/11.

E. Based on random observation during the survey walk through, not all hazardous areas are separated from the exit access route. The Facility Life Safety Plans designate the Basement Level as a Business Occupancy (the Basement is not fully sprinkler protected). The Life Safety plans do not distinguish between walls and fences for the separation of hazardous areas. The surveyor observed spaces greater than 100 square feet with a fence used for separation from the exit access route. The amount of stored combustible items open to the designated exit route does not comply with 39.3.2 and 8.4 for a means of fire rated separation.

New 02/02/2012: Second Floor, the door to the Dirty Utility Room 236E adjacent to Toilet 263D is not rated to comply with 19.3.6.3.2.

A. Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. Locations observed:

1. Stair referred to as Unit A, North Stair contains direct entry to mechanical rooms at two separate levels (3rd and 4th) which does not comply with 7.1.3.2.1.

2. The facility does not comply with 7.7.1 or 7.7.2 for the required number of exits permitted to discharge through areas on the level of exit discharge. Of the five stairs observed, three contain non compliant exit components. Stairs serving upper floor levels discharge as follows:
A. Unit B Central stair discharges to the interior of the building on the first floor.
B. Unit B East Stair discharges to an exit passageway.
C. Unit B West Stair discharges on the first floor to the MOB with a deficient discharge.
D. Unit A Center stair discharges interior to a non compliant exit passageway.
E. Unit A North Stair discharges interior to a non compliant exterior discharge.

B. Based on random observation during the survey walk through it was noted that not all exit components are provided with elements which maintain the fire resistant rating of the enclosure. Surveyor observed in numerous locations exit door hardware components which contained a brass knob.
Example locations observed:

1. First floor level "Forum" Stair entry door.

C. Based on random observation during the survey walk through not all exit components are protected from exposure to wall openings in other parts of the building. Location observed:

Basement floor level and all levels above - Exiting Stair from Basement "Laurndry" contains windows within the stairway which are not fire resistant to maintain the stair enclosure. These windows do not comply with 8.2.5.4 and 7.2.2.5.2 for exposure to building window openings that are within 10 feet of the stair and at an angle of less than 180 degrees.

D. Based upon random observation ,the surveyor finds that vertical opening and protection of vertical openings are not installed and maintained in accordance with Section 8.2.3.2 and 8.2.5: Location observed: Basement Floor, Stair adjacent to Paint shop, contains ductwork passing through the Stair that do not serve the stair. Due to the location of the duct penetration within the Paint Shop wall the surveyor was unable to determine the presence of a damper installation.

A. Based upon random observation during the survey walk through, travel distances to exits do not appear to comply with 19.2.6. for buildings which are not fully sprinkler protected. The maximum travel distance to the nearest exit shall not exceed 100'. Location observed:

Second Floor ICU, patient sleeping rooms located along the South East side of the ICU appear to be provided with a travel distance to the nearest exit that appears to exceed 150 feet and does not comply with 19.2.6.2.2. The Stair located on the East end of ICU has a 46" wide corridor that does not comply with 19.2.3.3. Therefore, this Stair cannot be counted as an exit stair for the ICU.

A. 1. a. Corrected 08/10/11.
b. Corrected 08/10/11.

B. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. locations include:

1. Corrected 08/10/11.

2. 3rd floor, Corridor outside the Nursery does not contain two means of exit, creating a 76' dead-end corridor.


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New 08/10/2011-12:40PM: Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

1. a. Corrected 02/02/2012
b. Corrected 02/02/2012







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C. Based upon random observation, the surveyors find that paths of egress within a Business Occupancy (as shown on the facility Life Safety Plans) are not provided and maintained as a protected path to a public way.

1. The Basement Level contains multiple locations where the common path of travel exceeds the maximum in order to comply with 39.2.5.3 for distance to an exit. Example locations include but are not limited to:

a. Refuse Discharge room.
b. Soiled Linen room located in the South West corner of the floor plan.
c. Corridor adjacent to the Boiler room and the Incinerator room.

D. Based on random observation during the survey walk through, there are numerous designated exit access corridors with one means of egress which does not comply with 19.2.5.9. Further the exception provided under 19.2.5.10 for permitted dead end corridors to remain does not appear to apply. Example locations observed:

1. Corrected 02/02/2012
2. Second Floor corridor leading to ICU and Endoscopy.

A. Based on observation, the surveyors finds that the various areas appear to be a patient sleeping suites (see K038 and K048). However, there do not appear to be two remote exit access doors to comply with 19.2.5.2. Example location observed:

1. Second Floor ICU, does not appear to have two remote exits.

2. Second Floor ICU, appears to exceed the maximum 5000 square feet permitted for a patient sleeping suite to comply with 19.2.5.6.


B. Based on observation, the surveyors finds that the various areas appear to be non-sleeping suites (see K038 and K048). However, there do not appear to be two remote exit access doors to comply with 19.2.5.2. Example location observed:

1. Second Floor Endoscopy. The exit path to the South is not permitted due to the excessive dead end corridor condition that would be produced by providing a suite at the end of a corridor. Location of the corridor is adjacent to the ICU waiting room (refer to K-Tag 038).

2. Corrected 08/10/11.

A. 1. a. Corrected 02/02/2012
b. Corrected 02/02/2012
B. 1. Corrected 08/10/11.
2. Corrected 08/10/11.
3. Corrected 08/10/11.
4. Corrected 08/10/11.






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C. Based on random observation during the survey walk through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. Locations observed:

1. Stair referred to as Unit A Center Stair at first floor level - discharges internally to an exit passageway which contains unoccupied storage rooms directly connected to the exit passageway. This does not comply with 7.1.3.2.1 (d) for access from normally occupied spaces.

2. (complaint investigation survey dated 9/22/10) Stair referred to as Unit B West Stair contains an interior vestibule which serves as the temporary Hospital Main Entry and exits to the MOB. The provided Life Safety Floor Plans designate a 2-hour separation between the two buildings. The surveyor observed existing unrated glazing and mullions within the designated 2- hour barrier (appears that this was once an exterior wall). Location observed above the ceiling of the barrier on the Hospital side of the vestibule.
This does not comply with 19.1.2.1 and 19.1.6.2 for construction type requirements for a Hospital facility.

UPDATE: During the survey walk through (as a follow up to the complaint investigation survey dated 9/22/10) the designated 2-hour fire rated barrier was re-designated to the East wall at the Medical Office Building (MOB) side of the vestibule. The re-designation is not complete.
The temporary Hospital Main Entry is considered as part of the Hospital building and not the MOB. Therefore, refer to K-Tag 051 and K-Tag 011 for deficiencies associated with the lack of a 2-hour barrier between construction types.

A. The facility's Life Safety Code Master Plan (latest plan-dated November 23, 2010) was unclear and not legible. Information is not available that is necessary to identify compliance with smoke barriers and complying smoke compartments.

1. Does not include the size (area) of each smoke compartment.

2. The line quality and size of the of the floor plans on the drawing sheets were difficult to read. Locations and sizes of "suites" could not be verified.

3. Designations for sprinklered and non sprinklered areas as shown on the Life Safety Code Master plan does not match what the surveyors have observed during the facility walk through.

4. The designation of hazardous areas in sprinklered and non sprinklered compartments is not complete. For example the boiler room, the incinerator room, the refuse and soiled linen discharge rooms and large storage areas.

A. Based on random observation during the survey walk-through and staff interview, not all portions of the building fire alarm system are installed in accordance with 19.3.4 findings include:

On the morning of 12/1/10, the fire alarm system within the adjacent Medical Office Building was activated. The alarm was not annunciated within the hospital. During an interview held in the Hospital's Temporary Main Lobby at the time of the incident the provider's staff and local fire department stated that the fire alarm system had been activated by a faulty smoke detector located within that Lobby. It is noted that, because it is not separated from the remainder of the Hospital by minimum 2 hour fire rated construction in accordance with 19.1.1.4.1., the Temporary Main Lobby is within the Hospital. Therefore, the activation of the smoke detector did not initiate the Hospital's fire alarm system as required by 9.6.2.1.

Update 02/02/2012: The surveyor was not able to conduct a test for the fire alarm system due to time constraints during this visit.




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B. Corrected 02/02/2012



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C. During document review and staff interview, concerning the Inspection and Testing of the Fire Alarm System a written statement under the remarks section, of a current inspection (dated 6-28-2010) read that "21 dampers could not be accessed due to construction".
During discussion with the facility representatives, the facility understood that the next testing and maintenance of these dampers will be required upon completion of the project building addition.

Therefore, the facility does not yet have a current complete Fire Alarm Inspection of the existing facility to comply with NFPA 72.

Interim Life Safety Measures are to be implemented prior to the completion of testing and maintenence.


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D. Based on random observation during the survey walk-through, not all portions of the facilities fire alarm system are installed in accordance with NFPA 72 1999. Elevator equipment rooms were observed without smoke detection installed in accordance with 3-9.3.7 (c).

A. Based on random observation during the document review process, documentation of annual sprinkler inspection from the floor level was not available in accordance with NFPA 25 1998 2-2.1.1.

A. 1. Corrected 08/10/11.





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B. Based on random observation during the survey walk-through not all portion of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA-13 (1999). The findings include:

1. The fire pump normal electrical service is not tapped ahead of the building main service disconnect as required by NFPA-70-695-3(a)(1).

2. The transfer switch for the fire pump is not located at the pump location as required by NFPA- 20-6-6.5, and NFPA-70-695-12.

3. The fire pump disconnect is not lockable as required by NFPA-70-695-4(b)(2).

4. Corrected 02/02/2012

5. The local and remote alarm for the fire pump does not monitor the four points required by NFPA-20-7-4.6 and 7-4.7.

6. The fire pump disconnect is not properly marked as required by NFPA-70-4(b)(3).



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C. Based on random observation during the survey walk-through, and fire alarm test, not all portions of the automatic sprinkler system are installed in accordance with NFPA 13 1999 and NFPA 25 1998. Findings include:

1. Corrected 08/10/11.

2. Control valves throughout the facility were observed chained in the open position and not electrically supervised in accordance with NFPA 13 5-14.1.1.3 (1).

3. Sprinkler control valves were observed without identification signs describing the area controlled in accordance with NFPA 25 9-3.2.

4. Sprinkler valves were observed without tags to identify the component of the sprinkler system in accordance with 3-8.3.

A. Based on random observation during the survey walk through, staff interview, and document review, not all portions of the facility's air conditioning and ventilation systems are installed and maintained to comply with NFPA 90A 1999.

1. Corrected 02/02/2012
2. Corrected 02/02/2012
3. Corrected 02/02/2012

4. Location observed - Ground Floor Medical Records Storage adjacent to room # G-5 contains two ducts penetrating the corridor wall above the entry door which lack damper installations.

5. Location observed - Basement pump room - two large ducts penetrate the room from the corridor side for which dampers could not be verified due to the lack of access panels.

6. Corrected 02/02/2012.



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7. Corrected 02/02/2012

A. The Surveyor finds that manual medical gas shutoff (zone) valves were located in the same room as the station outlets and inlets they serve which does not comply with NFPA 99 1999 4.3.1.2.3.(d).
Locations observed:

1. Second Floor - Recovery room - the manual
medical gas shutoff (zone) valve is located on the East wall of this area adjacent to office areas and is open to the station outlets within the patient bays.

2. 3rd floor, Recovery (378) the medical gas shut off is not physically seperated from the patients it serves. There is no door separating the shut off from the patient care area it serves.

A. By random observation the surveyor finds:

1. Corrected 02/02/2012
2. Corrected 02/02/2012
3. Corrected 02/02/2012
4. Corrected 02/02/2012

5. Since the load on the essential electrical system is over 150 KVA, Transfer switches are required to be dedicated to either the life safety branch, the critical branch, or the equipment branch of the emergency power system in accordance with NFPA-99-3-4.2.2.1, and NFPA-70-517-30(b)(4), and Figure 517-30(b).

A. 4.6.10 Construction, Repair, and Improvement Operations; 4.6.10.1 "Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place."

Hourly fire watches are conducted due to an ongoing construction project (which has been submitted to this Division). Due to this project, the fire alarm system is at various locations and times is shut down. The facility does monitor the system during construction; however, after 3:30pm the fire alarm system is put back on line. Documentation provided by the facility does not indicate the following:

1. A remote station (fire department) acknowledges the system being placed in trouble or when it is back on line.

2. The Fire Watch logs do not indicate deficiencies observed or abated. The Facility lacks a written protocol and schedule for all such measures.

3. The narrative does not describe all measures to be implemented, as well as the frequency with which they are to be conducted nor the manner in which the measures are to be documented.

4. Comments related to changes in the interim life safety measures to remain in place as work toward the project completion occurs are not present.


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. Based on random observation during the survey walk-through the building emergency electrical system is not divided into Life Safety, Critical, and Equipment Branches as required by NFPA-99 (1999) and NFPA-70 (1999). The findings include:

1. Throughout the facility panelboards and transfer switches are not clearly labeled as life safety, critical or equipment branch, and the loads served are not limited to the specific branch of emergency power required by NFPA-99-3-4.2.2.2 and 4.2.2.3.

2. The ICU rooms have all receptacles on the bedroom headwall served from the same emergency circuit and do not have a normal power receptacle in accordance with NFPA-70-517-19(b)(1).

3. The intermediate care rooms on the fourth floor are require to have an emergency receptacle on the headwall at each bed location to meet the requirements of NFPA-99-3-4.2.2.2(c)8.a.

A. 4th floor, IMC patient room in the North Wing are not provided with emergency electrical outlets on the head wall.


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B. Based on random observations during the survey walk-through not all portions of the building electrical systems are installed in accordance with NFPA-70 (1999). The findings include:

1. Corrected 02/02/2012

2. Corrected 02/02/2012


3. Corrected 02/02/2012

4. Corrected 02/02/2012

5. Panels throughout the building other than those in the seventh floor alcove adjacent to the mechanical room need to be marked as normal, life safety, critical or equipment branch to comply with NFPA-70-700-9 and NFPA-99.

6. Test records were not available for isolated power systems in accordance with NFPA-99-3-3.3.4.2.



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C. Corrected 02/02/2012



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D. The emergency department patient exam/treatment rooms were observed with a total of 4 outlets and not 6 outlets in accordance with 517-19 (b) 1.

A. Safety Code for Elevators and Escalators ASME A17.1a - 1994 rule 1206.7 "All elevators provided with firefirghters' service shall be subjected monthly to Phase I recall and a minimum of one-floor operation on Phase II to assure the system is maintained in proper operating order. A written record of findings on the operation shall be made and kept on the premises of said operation".

1. The existing Elevator #10 was referred to as having no automatic fire department recall. This Surveyor observed the Annual inspection report from an outside vender, which indicated that all elevators within the building with the exception of the freight elevator contain both phase I and II fire fighter recall. However, the facility does not comply with 9.4.6 for a monthly documented inspection of their elevators. Upon requesting these documents and stating that a recall test could be conducted, representative for maintenance commented that they had not dealt with the elevators in 4 years. The representative was unable to clarify the primary floor level or the secondary floor level for elevator recall. Therefore, the surveyor did not conduct a test of elevator recall.