HospitalInspections.org

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

B. 1. Corrected 08/10/11.
2. Corrected 05/29/2013.


16339


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


20224


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. Corrected 12/10/12
c. Corrected 7/11/12.

UPDATE 05/29/13: The Refuse Discharge Room and the Soiled Linen Room are located at the end of a dead end corridor that is not sprinklered; other rooms accessed from this corridor are also unsprinklered. The common path of travel from the interior of these rooms to the nearest exit access permitting access to two separate exit paths exceeds the 50 feet permitted under 42.2.5.4. The building is not protected throughout by an approved, automatic sprinkler system which precludes the use of the exception allowing a 100 foot common path of travel.

D. 1. Corrected 02/02/2012
2. Corrected 05/29/2013.

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.

UPDATE 7/11/12: Although revised and updated Life Safety Master Plans have been compiled, random verification of accuracy has not been completed. Some decrepancies regarding suite and corridor designations, exiting arrangements and completion of work to match the revised plans have been noted during plan review of current projects. Verification of Life Safety Plans with actual construction should be undertaken as projects are completed and inspected. This tag should remain until all Plan of Correction work is completed.

UPDATE 5/29/2013: Areas of the basement that were classified as a Storage occupancy and identified on the Life Safety Code master plan as being sprinklered were observed to not have sprinkler heads. An example is the corridor that serves the Refuse Discharge Room and the Soiled Linen Room. Further, there were locations where ducts in excess of four feet in width obstructed sprinkler coverage. An example is in the exit corridor that serves the fenced storage areas within the Storage occupancy.

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.

Update 7/11/12 - Surveyor notes that the temporary lobby function no longer exists due to the completion of the main lobby project. However, testing of the fire alarm system relative to the operation of the doors and verification of the 2-hour barrier was not completed during this survey visit.

UPDATE 5/29/2013: The two hour rated fire separation between the Medical Office Building and the Hospital was observed to be incomplete. The fire separation located at the door between the MOB and the stair discharge passageway extended above the door frame then turned and formed the two hour rated ceiling. The remaining portion of the wall above the door frame did not appear to be completed as 2-hour rated construction, thus the areas above the ceiling were actually still a part of the MOB. Further, the two hour rated ceiling was not independently supported; it was suspended by tie rods from the concrete floor deck and roof deck. The tie rods were unprotected and exposed to the MOB as described above. This condition was confirmed by inspection of the construction drawings for this area. Also, it was observed that the 1 1/2 hour rated pairs of doors that serve both sides of the stair discharge passageway had fire exit hardware with top rods only, there was no means of securing the bottoms of the doors. Although the stair discharge passageway appeared to be constructed to comply with the requirements for an exit passageway it was not identified as such on the Life Safety Master Plan, and it is not known if the intent of this area is to be in compliance with the requirements of 7.7.2.



17659


B. Corrected 02/02/2012


20224


C. Corrected 5/29/2013


26665


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).

Update 7/11/12 - Smoke detection (at elevators 1 thru 10 equipment areas) and heat detection (at elevators 11 & 12) was observed to have been installed. However, testing of the detection to confirm control of the elevator recall system was not acomplished during this survey visit or documentation reviewed.

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).


UPDATE 5/29/2013: It was observed that some of the transfer switches in the generator room and in the penthouse were not identified as to which branch they serve. Compliance could not be verified.

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.

UPDATE 5/29/2013: At the time of this survey the facility indicated that there were no ISLMs in force as there were no construction projects under way, but projects were anticipated.


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.

UPDATE 5/29/2013: It was observed that some of the transfer switches in the generator room and in the penthouse were not identified as to which branch they serve. Compliance could not be verified.

2. Corrected 5/29/2013
3. Corrected 12/10/12

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.

Update 7/11/12 -
a. Elevator recall for elevator #10 was tested as part of IDPH project #9337 to confirm compliance. Upon testing where the primary discharge level at the Ground floor lobby smoke detector was activated, the elevator returned to the Ground floor level rather than the designated secondary level at the 1st floor in non-compliance with requirements.

b. Upon review of the monthly elevator recall testing, it was not clear that proper understanding of the operation of the recall system was known by personnel performing the testing. It was not clear that both Phase I and Phase II operations are being tested. Comments on reports appeared to indicate an understanding that the elevators did not operate as intended, but from the information available, they had operated as required.

UPDATE 5/29/2013: It was observed that lobby smoke detectors have been installed, however the facility indicated that the replacement of the elevator controllers that will enable the elevators to comply with the Phase II elevator recall requirements is still pending. In order to monitor compliance it is recommended that the facility develop a schedule identifying milestone dates for the installation of the elevator recall for each elevator and submit it with their Plan of Correction.