HospitalInspections.org

Based on observation and interview it was determined the facility failed to properly maintain 2-hour fire rated common walls in four of fifteen smoke compartments in this component.

Findings include:

A. Observation on November 9, 2011 between 8:52 AM and 9:02 AM, revealed the following 2-hour fire rated common wall deficiencies:

1. 8:52 AM - First floor, common wall above double set of doors at Children ' s to HfAM. Facility is to verify and provide documentation detailing how the 2-hour fire rating is maintained when transitioning from 4 layers of type-X drywall to the shaft wall assembly.

2. 9:02 AM - First floor, common wall above Won doors at Children ' s to HfAM has large gap that extends through the wall above the door. Facility is to verify and provide documentation as to the exact location of the 2-hour fire rated common wall in this area.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed these common wall deficiencies.

Based on observation and interview, it was determined the facility failed to maintain common walls in one instance in one of forty-six smoke compartments within this component in accordance with NFPA 101.

Findings include:

A. Observation of 2-hour fire rated common wall doors on November 9, 2011, at 10:08 AM revealed an excessive gap between the double doors serving the common wall located within the Operating room department, second floor AGP leading to HFAM.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the common wall deficiency.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one instance in forty-six of forty-six smoke compartments within this component in accordance with NFPA 101.

Findings include:

A. Observation of building construction between November 9, 2011, and November 10, 2011, between the hours of 8:00 AM and 11:00 AM revealed the facility exceeds maximum allowable story height for this type of construction.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the facility exceeds maximum allowable story height for this type of construction and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on November 10, 2011, addressing this issue.

B. Observation of building construction on November 9, 2011, at 9:55 AM revealed the first floor Foss Clinic information desk in the construction of this area had used combustible framing lumber

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM confirmed the area had used combustible framing lumber.

Based on observation and interview it was determined the facility failed to properly maintain exit corridor doors in one of fifteen smoke compartments in this component.

Findings include:

A. Observation on November 9, 2011, at 9:17 AM, revealed the lower level one, Nurse Educator ' s office corridor door was being held open by an unauthorized wooden wedge.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the unauthorized wooden wedge.

Based on observation and interview it was determined the facility failed to properly protect vertical openings in 1 of 24 smoke compartments in this component.
Findings include:

A. Observation on November 10, 2011, at 8:48AM revealed the eighth floor north IT data room had an unprotected vertical penetration around two 6 inch diameter conduits.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed this vertical penetration deficiency.

Based on observation and interview, it was determined the facility failed to construct and maintain vertical enclosures in seven instances in seven of forty-six smoke compartments within this component.

Findings include:

A. Observation of vertical enclosures between November 9, 2011, and November 10, 2011, between the hours of 8:00 AM and 11:00 AM revealed vertical enclosures had less than the required fire resistive rating. These enclosures consist of HVAC shafts, exit stair towers, mechanical chases, and elevator/dumbwaiter shafts.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the vertical enclosures lacked the required fire resistive rating and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on November 10, 2011, addressing this issue.

B. Observation of vertical enclosures on November 9, 2011, at 9:50 AM and revealed the first floor Foss Clinic tele-lift shaft had several horizontal penetrations around wires.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM confirmed the horizontal penetrations.

Based on documentation review, observation and interview, it was determined the facility failed to provide acceptable travel distances in forty-six of forty-six smoke compartments in this component.

Findings include:

Observation of travel distances between November 9, 2011, and November 10, 2011, between the hours of 8:00 AM and 11:00 AM revealed extended smoke zones located in Bush Pavilion, Foss Clinic, Abigail-Geisinger Pavilion and Geisinger Pavilion. Total square footage of these identified zones each exceeds 22,500 square feet.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the extended travel distances and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on November 10, 2011, addressing this issue.

Based on observation and interview, it was determined the facility failed to construct the smoke barrier walls to provide at least a one half hour fire resistance rating in one instance in 1 of 24 smoke compartments in this component.

Findings include:

Observation of smoke barrier walls on November 10, 2010, at 10:25 AM revealed the smoke barrier wall located on the second floor did not extend to the outside wall on the East side.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the incomplete smokewall.

Based on observation and interview it was determined the facility failed to properly maintain hazardous areas in three of forty-six smoke compartments within this component.

Findings include:

A. Observation of hazardous areas on November 9, 2011, between 9:30 AM and 1:00 PM revealed:

1. 9:30 AM - The third floor, Foss Clinic room #346 being used for storage, lacked a self closing device on the door.

2. 10:36 AM - The first floor, Foss Clinic, storage closet located at the Information Desk area had an unauthorized louvered door.

3. 10:37 AM - The first floor, Foss Clinic, storage closet door located at the Information Desk area lacked a self closing device.

4. 1:00 PM - The second floor, Main Building, Dry Storage Room door could not close and latch properly.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the hazardous area deficiencies.

Based on observation and interview, it was determined the facility failed to provide two exits, remote one from another, in one of forty-six smoke compartments within this component in accordance with NFPA 101.

Findings include:

Observation of exit egress on November 9, 2011, at 9:05 AM revealed the lack of a second acceptable means of exiting from the 5th floor of the Main hospital wing.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the exit egress deficiency and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on November 10, 2011, addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain one exit passageway in 1 of 24 smoke compartments in the component.

Findings include:

Observation of exit components on November 10, 2011, at 10:30 AM revealed a penetration around a BX wire located in the first floor protected passageway above door #01022.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the penetration.

Based upon observation and interview, it was determined the facility failed to maintain required exit stair towers in six instances in three of forty-six smoke compartments within this component in accordance with NFPA 101.

Findings include:

A. Observation of exit stair towers on November 9, 2011, and November 10, 2011, between the hours of 8:00 AM and 11:00 AM revealed:

1. The Main Hospital fourth floor lacked required landing at the stair tower access door.

2. Abigail Geisinger Pavilion, west exit stair tower, had deficient headroom between the first and second floor landings.

3. Main Hospital north exit stair tower has deficient headroom between the basement and first floors.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed these exit egress deficiencies and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on November 10, 2011, addressing this issue.

Based on observation and interview it was determined the facility failed to properly maintain required exit access in 6 of 46 smoke compartments in this component.

Findings include:

A. Observation of exits on between November 9, 2011, and November 10, 2011, between the hours of 8:00 AM and 11:00 AM revealed the following deficiencies:

1. First floor, Main Hospital - corridor headroom is less than 6 feet 8 inches with a dead end corridor.

2. Lower level 1, Main Hospital - corridor headroom is less than 6 feet 8 inches.

3. Lower level 1, Geisinger Pavilion - corridor headroom is less than 6 feet 8 inches.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the deficient head room and existing dead end corridor and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on November 10, 2011, addressing this issue.

B. Observation of exit access on November 9, 2011, between 10:15 AM and 1:10 PM revealed:

1. 10:15 AM - The Lower level 1, Main Hospital, Tele-lift room door is locked with a manual dead-bolt.

2. 1:10 PM - The second floor soft drink storage room door was locked with a hasp and padlock.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the unauthorized dead-bolt and padlock.

Based on observation and interview it was determined the facility failed to properly maintain width of required exit corridors and aisles in 2 of 46 smoke compartments in this component.

Findings include:

A. Observation on November 9, 2011, between 9:31 AM and 1:15 PM revealed the following exit corridor/aisle deficiencies:

1. 9:31 AM - Third floor Abigail Geisinger Pavilion, Anesthesia on-call suite exit aisle was obstructed by a table and two chairs.

2. 1:15 PM - The Bush Pavilion sixth floor, south wing exit corridor width was obstructed by a table and boxes.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the exit corridors were obstructed

Based on observation and interview it was determined the facility failed to properly configure exit signage in 1 of 46 smoke compartments in this component.

Findings include:

Observation of exit signage on November 9, 2011, at 1:17 PM revealed the first floor corridor exit sign, Main Hospital adjacent to Environmental Services was obstructed by a cart.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the exit sign was obstructed.

Based on observation and interview it was determined the facility failed to properly configure Heating ventilation and cooling (HVAC) ducts in 2 of 46 smoke compartments in this component.

Findings include:

A. Observation of HVAC systems on November 9, 2011, between 8:30 AM and 9:15 AM revealed:

1. 8:30 AM - Eighth floor, Foss Clinic, HVAC duct traveling through floor slab to seventh floor has fire damper located 2 feet above floor. Facility to verify and provide documentation the fire damper is located at the floor slab.

2. 9:15 AM - Fourth floor, Foss clinic, unenclosed HVAC duct located in room 414, running from second floor to fifth floor lacks fire damper inspection access. Facility to verify and provide documentation that fire dampers have been properly installed at each of the four floor slab penetrations.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed these HVAC deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain soiled linen chute termination rooms in 1 of 24 smoke compartments in this component.

Findings include:

Observation of soiled linen chute termination rooms on November 10, 2011, at 9:15 AM revealed the Lower Level One soiled linen chute termination room had sheet metal plates compromising the required two-hour fire resistive integrity of the enclosure.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the unrated plates used.

Based on observation and interview it was determined the facility failed to properly configure medical gas storage rooms in 1 of 24 smoke compartments in this component.

Findings include:

A. Observation on November 10, 2011, at 8:47 AM revealed the eighth floor equipment storage room used to store oxygen cylinders, had electrical receptacles and light switches lower than 60 inches above the floor.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed this medical gas storage area deficiency.

Based on observation and interview it was determined the facility failed to properly configure medical gas storage rooms in 5 of 46 smoke compartments in this component.

Findings include:

A. Observation on November 9, 2011, between 8:45 AM and 12:30 PM revealed the following deficiencies:

1. 8:45 AM - Seventh floor, Foss Clinic, infusion room, not properly configured for oxygen cylinder storage.

2. 9:25 AM - Fourth floor, Foss Clinic, room 400, not properly configured for oxygen cylinder storage.

3. 10:15 AM - Second floor, Abigail Geisinger Pavilion, room 02170, oxygen storage within 5 feet of combustibles.

4.10:24 AM - First floor, Abigail Geisinger Pavilion, Endoscopy Department computer room, used to store oxygen cylinders, had electrical receptacles and light switches lower than 60 inches above the floor.

5.12:30 PM - Second floor, Geisinger Pavilion, equipment storage room located across from room 219 used to store oxygen cylinders, had electrical receptacles and light switches lower than 60 inches above the floor.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed these medical gas storage area deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain elevator one common elevator shaft affecting 8 of 46 smoke compartments in this component.

Findings include:

Observation on November 9, 2011, at 12:55 PM, revealed the Bush Pavilion elevator pit, serving elevators 19 through 21, had a large quantity of combustible trash accumulated on the floor of the elevator shaft.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the combustible trash in the elevator pit.

Based on observation and interview it was determined the facility failed to properly maintain installed electrical distribution system in one of fifteen smoke compartments in this component.

Findings include:

A. Observation on November 9, 2011, at 9:22 AM, revealed two electrical junction boxes were missing required cover plates above the suspended ceiling at the top of the " Grand Staircase " located on Lower Level 1.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the missing electrical junction box covers.

Based on observation and interview it was determined the facility failed to properly maintain installed electrical distribution system in 1 of 46 smoke compartments in this component.

Findings include:

Observation of electrical systems on November 9, 2011, at 9:18 AM revealed the fourth floor East stairway, had an eletrical wire which was not terminated into junction box.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the exposed electrical wire.

Based on observation and interview it was determined the facility failed to properly maintain 2-hour fire rated common walls in four of fifteen smoke compartments in this component.

Findings include:

A. Observation on November 9, 2011 between 8:52 AM and 9:02 AM, revealed the following 2-hour fire rated common wall deficiencies:

1. 8:52 AM - First floor, common wall above double set of doors at Children ' s to HfAM. Facility is to verify and provide documentation detailing how the 2-hour fire rating is maintained when transitioning from 4 layers of type-X drywall to the shaft wall assembly.

2. 9:02 AM - First floor, common wall above Won doors at Children ' s to HfAM has large gap that extends through the wall above the door. Facility is to verify and provide documentation as to the exact location of the 2-hour fire rated common wall in this area.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed these common wall deficiencies.

Based on observation and interview, it was determined the facility failed to maintain common walls in one instance in one of forty-six smoke compartments within this component in accordance with NFPA 101.

Findings include:

A. Observation of 2-hour fire rated common wall doors on November 9, 2011, at 10:08 AM revealed an excessive gap between the double doors serving the common wall located within the Operating room department, second floor AGP leading to HFAM.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the common wall deficiency.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one instance in forty-six of forty-six smoke compartments within this component in accordance with NFPA 101.

Findings include:

A. Observation of building construction between November 9, 2011, and November 10, 2011, between the hours of 8:00 AM and 11:00 AM revealed the facility exceeds maximum allowable story height for this type of construction.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the facility exceeds maximum allowable story height for this type of construction and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on November 10, 2011, addressing this issue.

B. Observation of building construction on November 9, 2011, at 9:55 AM revealed the first floor Foss Clinic information desk in the construction of this area had used combustible framing lumber

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM confirmed the area had used combustible framing lumber.

Based on observation and interview it was determined the facility failed to properly maintain exit corridor doors in one of fifteen smoke compartments in this component.

Findings include:

A. Observation on November 9, 2011, at 9:17 AM, revealed the lower level one, Nurse Educator ' s office corridor door was being held open by an unauthorized wooden wedge.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the unauthorized wooden wedge.

Based on observation and interview it was determined the facility failed to properly protect vertical openings in 1 of 24 smoke compartments in this component.
Findings include:

A. Observation on November 10, 2011, at 8:48AM revealed the eighth floor north IT data room had an unprotected vertical penetration around two 6 inch diameter conduits.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed this vertical penetration deficiency.

Based on observation and interview, it was determined the facility failed to construct and maintain vertical enclosures in seven instances in seven of forty-six smoke compartments within this component.

Findings include:

A. Observation of vertical enclosures between November 9, 2011, and November 10, 2011, between the hours of 8:00 AM and 11:00 AM revealed vertical enclosures had less than the required fire resistive rating. These enclosures consist of HVAC shafts, exit stair towers, mechanical chases, and elevator/dumbwaiter shafts.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the vertical enclosures lacked the required fire resistive rating and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on November 10, 2011, addressing this issue.

B. Observation of vertical enclosures on November 9, 2011, at 9:50 AM and revealed the first floor Foss Clinic tele-lift shaft had several horizontal penetrations around wires.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM confirmed the horizontal penetrations.

Based on documentation review, observation and interview, it was determined the facility failed to provide acceptable travel distances in forty-six of forty-six smoke compartments in this component.

Findings include:

Observation of travel distances between November 9, 2011, and November 10, 2011, between the hours of 8:00 AM and 11:00 AM revealed extended smoke zones located in Bush Pavilion, Foss Clinic, Abigail-Geisinger Pavilion and Geisinger Pavilion. Total square footage of these identified zones each exceeds 22,500 square feet.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the extended travel distances and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on November 10, 2011, addressing this issue.

Based on observation and interview, it was determined the facility failed to construct the smoke barrier walls to provide at least a one half hour fire resistance rating in one instance in 1 of 24 smoke compartments in this component.

Findings include:

Observation of smoke barrier walls on November 10, 2010, at 10:25 AM revealed the smoke barrier wall located on the second floor did not extend to the outside wall on the East side.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the incomplete smokewall.

Based on observation and interview it was determined the facility failed to properly maintain hazardous areas in three of forty-six smoke compartments within this component.

Findings include:

A. Observation of hazardous areas on November 9, 2011, between 9:30 AM and 1:00 PM revealed:

1. 9:30 AM - The third floor, Foss Clinic room #346 being used for storage, lacked a self closing device on the door.

2. 10:36 AM - The first floor, Foss Clinic, storage closet located at the Information Desk area had an unauthorized louvered door.

3. 10:37 AM - The first floor, Foss Clinic, storage closet door located at the Information Desk area lacked a self closing device.

4. 1:00 PM - The second floor, Main Building, Dry Storage Room door could not close and latch properly.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the hazardous area deficiencies.

Based on observation and interview, it was determined the facility failed to provide two exits, remote one from another, in one of forty-six smoke compartments within this component in accordance with NFPA 101.

Findings include:

Observation of exit egress on November 9, 2011, at 9:05 AM revealed the lack of a second acceptable means of exiting from the 5th floor of the Main hospital wing.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the exit egress deficiency and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on November 10, 2011, addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain one exit passageway in 1 of 24 smoke compartments in the component.

Findings include:

Observation of exit components on November 10, 2011, at 10:30 AM revealed a penetration around a BX wire located in the first floor protected passageway above door #01022.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the penetration.

Based upon observation and interview, it was determined the facility failed to maintain required exit stair towers in six instances in three of forty-six smoke compartments within this component in accordance with NFPA 101.

Findings include:

A. Observation of exit stair towers on November 9, 2011, and November 10, 2011, between the hours of 8:00 AM and 11:00 AM revealed:

1. The Main Hospital fourth floor lacked required landing at the stair tower access door.

2. Abigail Geisinger Pavilion, west exit stair tower, had deficient headroom between the first and second floor landings.

3. Main Hospital north exit stair tower has deficient headroom between the basement and first floors.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed these exit egress deficiencies and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on November 10, 2011, addressing this issue.

Based on observation and interview it was determined the facility failed to properly maintain required exit access in 6 of 46 smoke compartments in this component.

Findings include:

A. Observation of exits on between November 9, 2011, and November 10, 2011, between the hours of 8:00 AM and 11:00 AM revealed the following deficiencies:

1. First floor, Main Hospital - corridor headroom is less than 6 feet 8 inches with a dead end corridor.

2. Lower level 1, Main Hospital - corridor headroom is less than 6 feet 8 inches.

3. Lower level 1, Geisinger Pavilion - corridor headroom is less than 6 feet 8 inches.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the deficient head room and existing dead end corridor and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on November 10, 2011, addressing this issue.

B. Observation of exit access on November 9, 2011, between 10:15 AM and 1:10 PM revealed:

1. 10:15 AM - The Lower level 1, Main Hospital, Tele-lift room door is locked with a manual dead-bolt.

2. 1:10 PM - The second floor soft drink storage room door was locked with a hasp and padlock.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the unauthorized dead-bolt and padlock.

Based on observation and interview it was determined the facility failed to properly maintain width of required exit corridors and aisles in 2 of 46 smoke compartments in this component.

Findings include:

A. Observation on November 9, 2011, between 9:31 AM and 1:15 PM revealed the following exit corridor/aisle deficiencies:

1. 9:31 AM - Third floor Abigail Geisinger Pavilion, Anesthesia on-call suite exit aisle was obstructed by a table and two chairs.

2. 1:15 PM - The Bush Pavilion sixth floor, south wing exit corridor width was obstructed by a table and boxes.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the exit corridors were obstructed

Based on observation and interview it was determined the facility failed to properly configure exit signage in 1 of 46 smoke compartments in this component.

Findings include:

Observation of exit signage on November 9, 2011, at 1:17 PM revealed the first floor corridor exit sign, Main Hospital adjacent to Environmental Services was obstructed by a cart.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the exit sign was obstructed.

Based on observation and interview it was determined the facility failed to properly configure Heating ventilation and cooling (HVAC) ducts in 2 of 46 smoke compartments in this component.

Findings include:

A. Observation of HVAC systems on November 9, 2011, between 8:30 AM and 9:15 AM revealed:

1. 8:30 AM - Eighth floor, Foss Clinic, HVAC duct traveling through floor slab to seventh floor has fire damper located 2 feet above floor. Facility to verify and provide documentation the fire damper is located at the floor slab.

2. 9:15 AM - Fourth floor, Foss clinic, unenclosed HVAC duct located in room 414, running from second floor to fifth floor lacks fire damper inspection access. Facility to verify and provide documentation that fire dampers have been properly installed at each of the four floor slab penetrations.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed these HVAC deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain soiled linen chute termination rooms in 1 of 24 smoke compartments in this component.

Findings include:

Observation of soiled linen chute termination rooms on November 10, 2011, at 9:15 AM revealed the Lower Level One soiled linen chute termination room had sheet metal plates compromising the required two-hour fire resistive integrity of the enclosure.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the unrated plates used.

Based on observation and interview it was determined the facility failed to properly configure medical gas storage rooms in 1 of 24 smoke compartments in this component.

Findings include:

A. Observation on November 10, 2011, at 8:47 AM revealed the eighth floor equipment storage room used to store oxygen cylinders, had electrical receptacles and light switches lower than 60 inches above the floor.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed this medical gas storage area deficiency.

Based on observation and interview it was determined the facility failed to properly configure medical gas storage rooms in 5 of 46 smoke compartments in this component.

Findings include:

A. Observation on November 9, 2011, between 8:45 AM and 12:30 PM revealed the following deficiencies:

1. 8:45 AM - Seventh floor, Foss Clinic, infusion room, not properly configured for oxygen cylinder storage.

2. 9:25 AM - Fourth floor, Foss Clinic, room 400, not properly configured for oxygen cylinder storage.

3. 10:15 AM - Second floor, Abigail Geisinger Pavilion, room 02170, oxygen storage within 5 feet of combustibles.

4.10:24 AM - First floor, Abigail Geisinger Pavilion, Endoscopy Department computer room, used to store oxygen cylinders, had electrical receptacles and light switches lower than 60 inches above the floor.

5.12:30 PM - Second floor, Geisinger Pavilion, equipment storage room located across from room 219 used to store oxygen cylinders, had electrical receptacles and light switches lower than 60 inches above the floor.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed these medical gas storage area deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain elevator one common elevator shaft affecting 8 of 46 smoke compartments in this component.

Findings include:

Observation on November 9, 2011, at 12:55 PM, revealed the Bush Pavilion elevator pit, serving elevators 19 through 21, had a large quantity of combustible trash accumulated on the floor of the elevator shaft.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the combustible trash in the elevator pit.

Based on observation and interview it was determined the facility failed to properly maintain installed electrical distribution system in one of fifteen smoke compartments in this component.

Findings include:

A. Observation on November 9, 2011, at 9:22 AM, revealed two electrical junction boxes were missing required cover plates above the suspended ceiling at the top of the " Grand Staircase " located on Lower Level 1.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the missing electrical junction box covers.

Based on observation and interview it was determined the facility failed to properly maintain installed electrical distribution system in 1 of 46 smoke compartments in this component.

Findings include:

Observation of electrical systems on November 9, 2011, at 9:18 AM revealed the fourth floor East stairway, had an eletrical wire which was not terminated into junction box.

Exit interview with facility representatives #1 and #2, on November 10, 2011, between 11:00 AM and 11:30 AM, confirmed the exposed electrical wire.