HospitalInspections.org

An un-announced Verification Visit was performed on August 27, 2013 from a Recertification Survey for Life Safety Code compliance. The full survey was conducted by the Wisconsin Division of Quality Assurance on 05/13/2013 - 05/16/2013. The Wheaton Franciscan Health - St. Joseph Hospital was found to be NOT in compliance with the following regulation:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET
42 CFR 482.41(b) Standard: Safety from Fire was NOT MET

The cumulative effect of the following (A-TAG) deficiencies has the potential to affect the safety of all patients, staff, and visitors at the hospital:

FINDINGS INCLUDE:
K11: Unreliable building separation.
K15: Interior room finishes without flame spread ratings.
K17: Smoke tight corridors are not maintained.
K20: Compromised vertical shaft ratings.
K21: Rating doors on hold-open without automatic closing feature.
K22: Access to exits without readily visible signs.
K24: Smoke Compartments with inappropriate configurations.
K25: Smoke Compartment walls were not smoke tight.
K29: Unreliable enclosure of hazardous areas.
K32: Exits were not provided or properly remote from each other.
K40: Egress doors were undersized.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K67: The ventilation system did not meet NFPA 90A minimum standards.
K69: Kitchen was not properly protected per NFPA 96.
K74: Loosely hanging fabrics lacked treatment.
K130: Miscellaneous provisions not found in other K-tags.

(A-0709) Life Safety from Fire.
Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate Building found later in this report.

An un-announced verification visit occurred on 8/27/2013 as part of a quarterly review until all the tags are corrected. This was part of a Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 05/13/2013 - 05/16/2013. The Wheaton Franciscan Health - St. Joseph Hospital was found to be NOT in compliance with the following regulation:

42 CFR 482.41(b) Standard: Safety from Fire was NOT MET

The cumulative effect of these 16 K-tag deficiencies has the potential to affect the safety of all patients, staff, and visitors at the hospital.

FINDINGS INCLUDE:
K11: Unreliable building separation.
K15: Interior room finishes without flame spread ratings.
K17: Smoke tight corridors are not maintained.
K20: Compromised vertical shaft ratings.
K21: Rating doors on hold-open without automatic closing feature.
K22: Access to exits without readily visible signs.
K24: Smoke Compartments with inappropriate configurations.
K25: Smoke Compartment walls were not smoke tight.
K29: Unreliable enclosure of hazardous areas.
K32: Exits were not provided or properly remote from each other.
K40: Egress doors were undersized.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K67: The ventilation system did not meet NFPA 90A minimum standards.
K69: Kitchen was not properly protected per NFPA 96.
K74: Loosely hanging fabrics lacked treatment.
K130: Miscellaneous provisions not found in other K-tags.

Please refer to the full description and findings within the specific 16 K-tag deficiencies within the appropriate Building found later in this report.