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Based on observation and interview, the facility did not provide a common separation wall with rated doors, sealed wall penetrations, and rated wall construction. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/15/2011 at 10:33 am surveyor #18107 observed in the SC-03 smoke compartment on the 1st floor in the Separation between the Hospital & the new MOB/ACC at Corridor Connections, that a penetration was not sealed according to an approved method. The deficiency included a mechanical duct penetrating the 2-hour wall assembly and part of the duct was not fire-sealed properly where it penetrated the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide a common separation wall with rated doors, sealed wall penetrations, and rated wall construction. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 12:02 pm surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the Corridor between Hospital & MOB, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. Fire doors would not self-latch. Double doors missing coordinator. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 10:33 am surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the Separation between Hospital & new MOB at Corridor Connections, that penetration(s) were not sealed according to an approved method. The deficiency included a mechanical duct penetrating the 2-hour wall assembly and part of the duct was not fire-sealed properly where it penetrated the wall. This observed situation was not compliant with NFPA 101 (2000 edition), section 19.1.1.4; and section 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/16/2011 at 9:45 am surveyor #18107 observed in the SC-12 smoke compartment on the 1st floor in the Maternity and Infant Unit along the Separation Wall, that the separation wall was not constructed to have a 2-hour fire resistance rating because top of wall was open and not fire sealed as well as screws not double mudded and seams not taped in all places. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing, and support steel covered with rated fire proofing. This deficiency occurred in 7 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients & all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 8:25 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Air Handling Unit #3 Room, that fire proofing was missing from the structural steel beam or steel floor joist system. The ceiling assembly providing the fire protection to the floor assembly was not completed correctly. Screws were not double mudded and drywall seams were not taped. These deficiencies would allow hot gases and heat to penetrate the protection and effect the exposed steel joist flooring system beyond. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 11:30 am surveyor #18107 observed in the SC-13 smoke compartment on the 2nd floor in the Shell Space & Construction Material Storage Room, that fire proofing was missing from the structural steel at roof deck in a 2-Story Building Type II (111) plus steel angles supporting new concrete plank and steel clamps were not fire-protected. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 1:38 pm surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the Public Toilet Rooms, ER Vestibule & West Corridor next to Gift Shop, that fire proofing was missing from the structural steel at floor above ceiling tiles. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


4. On 11/15/2011 at 3:01 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Surgery Large Storage next to Surgery Receiving Room, that fire proofing was missing from the structural steel at floor assembly above ceiling tile. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

5. On 11/15/2011 at 5:00 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Surgery Suite including OR #1, OR #2, Sterile & Equipment Storage, Sterile Processing, Decontamination Room, Minor Procedure Room & Clean Corridor, that fire proofing was missing from the structural steel at roof assembly above ceiling tile. The roof is supported by steel trusses that are protected by a horizontal shaft wall assembly. The shaft wall assembly is not finished, drywall screws are not double-mudded and drywall sheet edges are not taped to the Underwriters Laboratory 'standard' or any standard not available at time of survey. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

6. On 11/16/2011 at 9:55 am surveyor #18107 observed in the SC-12 smoke compartment on the 1st floor in the Maternity Nurses Station and Staff Lounge, that fire proofing was missing from the structural steel at separation wall and was not fire protected to the required 2-hours where it became part of the separation wall to the connector. Steel clamps and steel beams were un-protected at places. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

7. On 11/16/2011 at 1:30 pm surveyor #18107 observed in the SC-18 smoke compartment on the Basement floor in the Mechanical & Air Handling Unit Room under Medical / Surgical Unit, that fire proofing was missing from the structural steel at floor assembly supporting inpatient sleeping rooms above. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

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Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing, and support steel covered with rated fire proofing. This deficiency occurred in 7 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 10:16 am surveyor #18107 observed in the SC-03 smoke compartment on the 1st floor of Building #2, in the Separation between the Hospital & new MOB/ACC near Room 144, that fire proofing was missing from the structural steel at floor/ceiling assembly at separation wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2 & 20.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 10:35 am surveyor #18107 observed in the SC-03 smoke compartment on the 1st floor of Building #2, in the Imaging Waiting, Lab Drawing, Medical Record Film Files Storage near separation wall, that fire proofing was missing from the structural steel at floor deck above ceiling. It also included steel clamps, supporting the sprinkler pipes, not fire-protected where attached to steel beams. This observed situation was not compliant with NFPA 101 (2000 edition), 20.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with no combustible material storage. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 2 of the 187 staff that were working.

FINDINGS INCLUDE:
On 11/15/2011 at 7:40 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Corridor, that the corridor space across from one of the two required exit stairways was used for storage, and was not separated by a wall from the corridor. Storage included many combustible items in boxes on shelving units covering an area of 2' x 6'. This quantity of materials was deemed hazardous for storage in a corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 , and 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide corridor separation doors with louver-free corridor doors, and doors that would close when pushed or pulled. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 9:30 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Dietary Office, that the door had a 24" x 24" size louver that did not resist the passage of smoke between the corridor and the room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 5:01 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the OR #1, OR #2, Surgery Sterile Storage, Surgery Sterile Processing & Surgery Decontamination Rooms), that the door to the corridor was held open with a door stop attached to the bottom of the door to prevent it from closing to the adjoining Surgery Clean Corridor or Aisle that is used for 'exit access' within the Surgery Suite, in the event of a fire. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with sealed wall an floor penetrations. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/15/2011 at 7:44 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Data Room, that penetration(s) in a vertical shaft or floor assembly were not sealed according to an approved method. The deficiency included multiple holes in the floor/ceiling assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with sealed wall or floor penetrations. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect all of the 574 out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/15/2011 at 10:17 am surveyor #18107 observed in the SC-03 smoke compartment on the 1st floor in the Imaging North Corridor, that penetrations in a floor assembly were not sealed according to an approved method. The deficiency included a 1/2 inch conduit penetration through floor assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent, and non-egress pathways without exit signs. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect 59 of the 154 staff that were working in the hospital controlled areas.

FINDINGS INCLUDE:
1. On 11/15/2011 at 8:15 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Storage Suite, that the path of egress in the corridor, aisle or passage was not readily apparent and an exit sign was not provided near the exit and was blocked by pipes, along with partial walls and stacked storage items. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 8:55 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Dining Room, that the path of egress in the corridor or aisle was not readily apparent and an exit sign was not provided near the exit access door from the dining room. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/16/2011 at 7:28 am surveyor #18107 observed in the SC-08 smoke compartment on the 1st floor in the Monumental Stairway next to SC-09 (smoke compartment), that an exit sign was installed at a location that the facility confirmed was 'not an exit'. This stairway adjoins a renovated hospital office area. The Basement does not require this 'exit egress' pathway per the revised Life Safety Plan. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/15/2011 at 2:24 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Surgery Women's Locker Room, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the top-of-wall was not sealed correctly. A continuous opening was present at top of wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with compliant smoke doors. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/16/2011 at 8:51 am surveyor #18107 observed in the door straddling the SC-10 & SC-12 smoke compartments on the 1st floor in the Data Closet/ Nurse Call/ TV Cabling, that the smoke barrier door was not compliant. The Data Room door was shown to be in the smoke barrier per the Life Safety Plans. The door has a 24" x 24" Grille/Louver in the door that is not permitted. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not enclose hazardous rooms with closer's on all doors, a smoke-tight room enclosure (in a sprinkled smoke zone), and sealed wall penetrations. This deficiency occurred in 4 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 9:15 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Kitchen Office, that the door would not self-close because it was missing a door closer. Per the Life Safety Plan used as reference during the Survey Tour, this room is shown as a hazardous space. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 2:01 pm surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the ER Soiled Utility Room & Ambulance Garage Room , that penetrations were not sealed according to an approved method. The deficiency included numerous screws, pipes & conduits penetrations. These observed situations were not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 4:42 pm surveyor #18107 observed in the SC-07 smoke compartment on the 1st floor in the Main Boiler Room, that penetrations were not sealed according to an approved method. The deficiency included screws in 2-hour fire-rated wall assembly were not double mudded, not meeting Underwriters Laboratory minimum requirements for this tested assembly and observed three (3) vacuum pipes plus numerous electrical conduit penetrations. These observed situations were not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide egress paths at all times with doors that opened with under 50 pounds of force, paths with sufficient headroom, door hardware that operated with a single release motion, paths that are maintainable in all weather conditions and level walking surfaces in the path of egress. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/16/2011 at 9:08 am surveyor #18107 observed in the SC-12 smoke compartment on the 1st floor in the Maternity & Child Health Corridor, that the door in the path of egress would not open when a force of greater than 50 lbs. pressure was applied to two Corridor egress doors, three Labor / Delivery / Recover (LDR) doors, and two Post Partum doors that exceeded the maximum 50 lbs. needed to open an existing exit access door due to door stops at bottom of these doors. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 7:29 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Corridor, that the headroom was 6'- 6-5/8" at center of corridor from a sprinkler pipe. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.5 headroom. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 8:54 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Dining Room, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a deadbolt to keep the door locked. This dining room can hold over 40 persons at any one time. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

4. On 11/15/2011 at 8:41 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Exit Discharge, that a portion of the path of egress had an abrupt change in elevation of greater than 1/2 inch at the stoop and door threshold. This observed situation was not compliant with NFPA 101 (2000 edition), sections 19.2.1, 7.1.6 and 7.1.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide all spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress with locks that activate within 3 seconds. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/16/2011 at 8:23 am surveyor #18107 observed in the SC-11 smoke compartment on the 1st floor in the Medical /Surgical Unit at the East and West Exit Discharge Doors, that a 'delayed egress lock' (DEL) did not activate within 3 seconds of pushing the release mechanism and the doors took greater than 30 seconds to activate the release of the door upon pushing the horizontal bar continuously for 3 seconds. Signage was missing next to the door or on the door to let persons wanting to leave the building in an emergency that these doors were delayed egress. The facility could not provide documentation showing these exit doors were permitted to be delayed 30 seconds upon activation of the push-bar to open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 8:30 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Exit Discharge, that the path of egress to the public way was not illuminated to at least 1 foot-candle. Facility could not confirm that lighting was on the emergency circuit and the lamps could produce 1 ft. candle along the entire route to a public way. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 8:45 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Dietary Stairwell, that the path of egress to the public way was not illuminated to at least 1 foot-candle. Lighting was missing at the exit discharge. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with the required quantity of drills. This deficiency occurred in 18 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/14/2011 at 4:00 pm surveyor #18107 observed in the Document Review the smoke compartment on the 1st floor in the Hospital & other attached Clinics, that during a review of facility documents the Fire Drill Report showed that fire drills were not conducted quarterly on every shift. Observed through documentation review that the 4th Quarter at 2nd Shift was missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The facility did not provide a fire alarm system with and smoke detectors at required locations. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as 6 hospital staff and visitors.

FINDING INCLUDEs:
On 11/16/2011 at 9:19 am surveyor #18107 observed in the SC-12 smoke compartment on the 1st floor in the Pantry open to the corridor and not visible from the nurses station, that the smoke detector was not located in accordance with NFPA 72 requirements. The smoke detector was missing in an area open to the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 & 9.6.1.4 and NFPA 72 (1999 edition), 2-2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The facility did not provide a sprinkler system with all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 8:20 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Air Handling Unit #3 Room, that the room was not sprinkler protected. A sprinkler head is missing in one of the corners. This observed situation was not compliant with NFPA 101 (2000 edition), section 9.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 9:14 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the AHU #12 Room, that the room was not sprinkler protected. A sprinkler head is missing at top of ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), section 9.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 3:05 pm surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the ER On-Call Shower Room & X-Ray Data Closet, that the room was not sprinkler protected. This observed situation was not compliant with NFPA 101 (2000 edition), section 9.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

4. On 11/16/2011 at 1:35 pm surveyor #18107 observed in the SC-18 smoke compartment on the Basement floor in the Mechanical & Air Handling Unit Room under Medical / Surgical Unit, that the room was not sprinkler protected. Mechanical ducts blocked sprinkler distribution in four (4) portions of the room. This observed situation was not compliant with NFPA 101 (2000 edition), sections 9.7 and 6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

5. On 11/15/2011 at 8:53 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Elevator #2 Equipment Room, that there was no sprinkler or approved alternative suppression measures. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.1 (exception). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

6. On 11/16/2011 at 7:34 am surveyor #18107 observed in the SC-09 smoke compartment on the 1st floor in the Physician On-Call Toilet /Shower Room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a shower curtain. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

7. On 11/16/2011 at 8:27 am surveyor #18107 observed in the SC-11 smoke compartment on the 1st floor in the Room #120 - Toilet / Shower Room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a shower curtain. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

8. On 11/16/2011 at 9:13 am surveyor #18107 observed in the SC-12 smoke compartment on the 1st floor in the Room # 131 - Toilet /Shower, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a shower curtain. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 10 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 9:27 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Kitchen Corridor, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the corridor and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 2:15 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Decontam Shower in Ambulance Garage, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 7:30 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Facility Office, Storage Suite & Record Storage Rooms, that there was one or more unsealed holes near the ceiling. The holes included numerous ceiling tiles missing or with holes in them from pipes, conduits or damaged tiles. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

4. On 11/15/2011 at 11:45 am surveyor #18107 observed in the SC-13 smoke compartment on the 2nd floor in the Shell Space & Construction Material Storage Room, that there was one or more unsealed holes near the ceiling. The holes included numerous openings along top-of-wall to roof deck. These holes would reduce the response time of the sprinklers in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

5. On 11/15/2011 at 2:26 pm surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the X-Ray Communications Closet, General Radiographic Room #1, X-Ray Janitor Closet & X-Ray Data Closet, that there was one or more unsealed holes near the ceiling. The holes included 1" diameter opening at pipe sleeve, 24" x 24" tiles out at two different rooms and 2-sleeves with 2" diameter openings. The Accounting Office Storage Closet had a sprinkler blockage. These holes and penetrations would reduce the response time of the sprinkler in their rooms or spaces and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

6. On 11/15/2011 at 3:33 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Print Room, that there was one or more unsealed holes near the ceiling. The holes included 4 ceiling panels missing. This holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

7. On 11/15/2011 at 3:50 pm surveyor #18107 observed in the SC-08 smoke compartment on the 1st floor in the Medical Records Room, that there was one unsealed hole near the ceiling. The hole included one fire alarm conduit penetration. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

8. On 11/16/2011 at 8:01 am surveyor #18107 observed in the SC-10 smoke compartment on the 1st floor in the Main East-West Corridor, that there was one unsealed hole near the ceiling. The hole included a ceiling tile open along one edge in corridor 1/2" x 24". This hole would reduce the response time of the sprinkler in the corridor and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

9. On 11/16/2011 at 8:53 am surveyor #18107 observed in the SC-12 smoke compartment on the 1st floor in the Data Closet/ Nurse Call/ TV Cabling, that there was one or more unsealed holes near the ceiling. The holes included numerous penetrations from wires in ceiling and parts of ceiling tiles were missing. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with accessible extinguisher. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 11 of the 154 staff that were working.

FINDINGS INCLUDE:
On 11/16/2011 at 7:40 am surveyor #18107 observed in the SC-09 smoke compartment on the 1st floor in the Hospital Biller's Workroom, that a fire extinguisher was not accessible for immediate use because it was blocked by a cart and shelving unit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.6, 9.7.4.1 and NFPA 10 (1998 edition) 1-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A. Facility is required to have regular damper maintenance and where present, plenum mechanical rooms free of storage. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/15/2011 at 8:21 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Air Handling Unit #3 Room, that the mechanical room was used as a plenum for air returning to the air handling unit and was used to store combustibles not used in the operation of the air handling unit per NFPA 90A. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 , 9.2 and NFPA 90A, 2-3.10.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96. Range hoods shall be cleaned semi-annually and extinguisher system shall be clearly identified. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 26 of the 154 staff that were working.

FINDINGS INCLUDE:
1. On 11/14/2011 at 3:00 pm surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Kitchen, that during a review of documents it was discovered that the range hood and ducts were not inspected and cleaned of grease contamination semi-annually, as required for systems serving moderate-volume cooking operations. Cleaning records indicated that only one annual inspection and cleaning were occurring for the kitchen hood and associated exhaust ducts. May 10, 2011 was the last day the kitchen hood was cleaned and inspected. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6; 9.2.3; and NFPA 96 (1998 edition), 8-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 9:05 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Kitchen, that a placard identification sign was not provided above the kitchen hood activation button or above the Type K fire extinguisher to identify their locations. Both were blocked by a kitchen cart. This observed situation was not compliant with NFPA 96 (1998 edition), Section 7-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping. This deficiency occurred in 2 of the 18 smoke compartments and had the potential to affect 10 of the 154 staff that were working.

FINDINGS INCLUDE:
1. On 11/15/2011 at 4:00 pm surveyor #18107 observed in the SC-08 smoke compartment on the 1st floor in the Medical Gas Storage & Manifold Room, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included missing medical gas flow direction via directional signage on the pipe itself. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Chapter 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 4:58 pm surveyor #18107 observed in the SC-07 smoke compartment on the 1st floor in the Main Boiler Room & adjoining Oxygen Storage Room, that medical gas piping was not installed according to the requirements of the Health Care Facilities - Medical Gas & Vacuum Systems Code. The inappropriate piping installation included missing exhaust venting where 'off-gassing' of oxygen is occurring, and missing direction flow signage on vacuum gas piping per section 4-3.2.2.11(h) running through the Main Boiler Room and Oxygen Storage Room. This observed situation was not compliant with NFPA 101 (2000 edition), section 19.3.2.4 and NFPA 99 (1999 edition), Chapter 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not ensure the facility was properly protected from hazardous spaces within its occupancy per NFPA 101 (2000 edition), section 39.1.5. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 23 of the 154 staff that were working in the hospital controlled areas.

FINDINGS INCLUDE:
Building #4 - On 11/16/2011 at 11:16 am surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Materials Management office area, that the room was not sprinkler protected completely along with other hazardous spaces in this area. The floor deck separating the Basement from the MOB above could not be confirmed to be fire-separated from the 1st Floor making it a 2-Story wood frame construction (not sprinkled). Since there is NO fire-separation between 1st Floor (MOB) and Basement (Support to Hospital Functions) due to seams not fire sealed at several locations of floor assembly, and this building was originally built as a 1-Story, Type V (000), the entire Basement and 1st Floor should be sprinkled since there is not separation from a hazardous area. This observed situation was not compliant with NFPA 101 (2000 edition), section 39.1.5 Hazard of Contents, section 6.2 Classification of Occupancy and section 39.1.5.2 where automatic sprinklers are used in a 'business occupancy' shall be classified as a light hazard occupancy in accordance with NFPA 13. Hazardous areas shall be separated from other spaces. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not provide proper protection from hazardous areas with the proper sprinkler system that complies with NFPA 101 (2000 edition), section 39.3.2 Protection from Hazards and section 8.4 Special Hazard Protection. Per section 8.4.1.1(2), area shall be protected with an automatic extinguishing system in accordance with section 9.7. Section 9.7 requires a NFPA 13, Standard for the Installation of Sprinkler Systems Installation. Based on NFPA 13, sprinklers were not free of obstructions near the ceiling and in the interstitial areas between acoustical tile ceiling and floor assembly. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 23 of the 154 staff that were working.

FINDINGS INCLUDE:
1. Building #4 - On 11/16/2011 at 11:14 am surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Materials Management main storage area, that the room was not sprinkler protected. Missing or blocked sprinkler heads above the ceiling through-out the Basement area. Due to sprinkler blockages, this does not meet minimum requirements for a sprinkled area. This observed situation was not compliant with NFPA 101 (2000 edition), sections 9.7 and 6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. Building #4 - On 11/16/2011 at 11:54 am surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Clinical Laboratory - Storage area, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included boxed storage items in close proximity to a sprinkler head. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent, and non-egress pathways without exit signs per NFPA 101 (2000 edition), section 39.2.10 Marking of Means of Egress. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect 59 of the 154 staff that were working in the hospital controlled areas.
FINDINGS INCLUDE:
Building #4 - On 11/16/2011 at 12:05 pm surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Exit Stairway, that the path of egress in the corridor or aisle was not readily apparent and an exit sign was not provided near the exit stairway. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not provide and maintain all exit access stairs with enclosure assemblies free of storage per NFPA 101 (2000 edition), 39.2.1 Means of Egress Requirements & all of Chapter 7 Impediments to Egress. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 23 of the 154 staff that were working.
FINDINGS INCLUDE:
Building #4 - On 11/16/2011 at 12:02 pm surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Exit Stairway, that a portion of the stair enclosure was being used as usable space (storage). The stairs was being used for storage of combustibles at the bottom of the stairs from 1st Floor and from this Basement Floor Level. The code requires that "there shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential of interfere with egress". This observed situation was not compliant with NFPA 101 (2000 edition), 39.2.1 Means of Egress Requirements and 7.2.2.5.3 Usable Space. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not ensure that corridors did not have excessively long dead-ends as permitted by the code with too long of dead-end corridors per NFPA 101 (2000 edition), 39.2.5.2 . This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 23 of the 154 staff that were working.
FINDINGS INCLUDE:
Building #4 - On 11/16/2011 at 11:26 am surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Clinical Laboratory - Histology Lab area, that a dead end corridor, aisle or passage of greater than 50 lineal feet was observed from the far back corridor outside the Histology Lab. The story is not fully-sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 39.2.5.2 for dead-end corridors exceeding 50 feet. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent, and non-egress pathways without exit signs per NFPA 101 (2000 edition), section 39.2.10 Marking of Means of Egress. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect 59 of the 154 staff that were working in the hospital controlled areas.
FINDINGS INCLUDE:
Building #3 - On 11/16/2011 at 11:09 am surveyor #18107 observed in the SC-14 smoke compartment on the 1st floor in the Connector, that the path of egress in the corridor or aisle was not readily apparent and an exit sign was not provided near the exit discharge that lead to the loading dock area, that lead to the public way. An exit directional sign was also missing in the corridor of the connector from the 2nd exit access of Maternity Unit. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with sealed shaft walls and floor penetrations per NFPA 101 (2000 edition), 39.3.1 Protection of Vertical Openings. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect one third of the 530 out-patients that the facility was licensed to serve, as well as 18 staff and an undetermined number of visitors.
FINDINGS INCLUDE:
Building #5 - On 11/15/2011 at 2:45 pm surveyor #18107 observed in the SC-17 smoke compartment on the 1st floor in the West Stairway, that penetrations in the floor assembly were not sealed according to an approved method. The deficiency included three holes near top-of-wall and above the acoustical tile ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not enclose hazardous rooms like boiler or furnace rooms with closer's on all doors per NFPA 101 (2000 edition), 39.3.2.1. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 1/3 of 530 out-patients that the facility was licensed to serve, as well as an undetermined number of visitors and 18 staff members.
FINDINGS INCLUDE:
Building #5 - On 11/16/2011 at 2:20 pm surveyor #18107 observed in the SC-16 smoke compartment on the Basement floor in the Mechanical & Boiler Room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of several unsealed holes. The holes included two holes in walls from either pipes or conduits that were removed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2.1, section 9.7 and 8.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not provide egress paths at all times with doors that opened with under 50 pounds of force, paths with in-sufficient headroom, door hardware that operated with a single release motion, paths that are maintainable in all weather conditions, and level walking surfaces in the path of egress per NFPA 101 (2000 edition), section 39.2.1. General-Means of Egress, 39.2.2.1 Means of Egress Components (Doors), and all of Chapter 7 Means of Egress. This deficiency effected 2 of the 18 smoke compartments, and had the potential to affect 1/3 of the 530 out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.
FINDINGS INCLUDE:
1. Building #5 - On 11/16/2011 at 2:31 pm surveyor #18107 observed in the SC-16 smoke compartment on the Basement floor in the Rehabilitation, Lymphoedema & Support areas, that the door would not open when a maximum 50 lbs. pressure was applied to the doors to open an existing exit access door due to door stops at bottom of these doors. The hardware included door stops attached to the bottom of several doors through-out the area. This observed situation was not compliant with NFPA 101 (2000 edition), sections 39.2.2.2.1 & 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).
2. Building #5 - On 11/16/2011 at 2:50 pm surveyor #18107 observed in the SC-17 smoke compartment on the 1st floor in the Corridor Suite doors, that the door release hardware required more than a single motion to release the door for exiting to the corridor. The suite entrance hardware included dead-bolts. This observed situation was not compliant with NFPA 101 (2000 edition), sections 39.2.2.2.2 and 7.2.1.5.1. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).
3. Building #5 - On 11/16/2011 at 2:37 pm surveyor #18107 observed in the SC-16 smoke compartment on the Basement floor in the South & West Exit Discharges to a Public Way, that the exit discharge path did not have a maintainable surface. The path of egress was composed of grass and mulch. There was no hard surface for rehabilitation patients to a public way from this exit discharge. This observed situation was not compliant with NFPA 101 (2000 edition), sections 39.2.7 and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure per NFPA 101 (2000 edition), section 39.2.9 Emergency Lighting and section 7.9 Emergency Lighting. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect 1/3 of 530 out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.
FINDINGS INCLUDE:
Building #5 - On 11/16/2011 at 2:09 pm surveyor #18107 observed in the SC-16 smoke compartment on the Basement floor in the two Exit Stairways and Exit Discharges, that the facility was unable to verify that the lighting along the path of egress was powered from the emergency electrical system. This observed situation was not compliant with NFPA 101 (2000 edition), 7.9.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not install and maintain a Automatic Sprinkler System according to NFPA 13 requirements per NFPA 101 (2000 edition), Section 9.7. The facility did not provide a sprinkler system with all rooms sprinkled when the facility told me that it was fully-sprinkled. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 1/3 of the 530 out-patients that the facility was licensed to serve, as well as an undetermined number of visitors and 18 staff members.
FINDINGS INCLUDE:
Building #5 - On 11/16/2011 at 1:55 pm surveyor #18107 observed in the SC-16 smoke compartment on the Basement floor in the Rehabilitation and Support areas, that the sprinkler installation was not compliant. The sprinklers were observed in several locations throughout this area to be blocked by cubical curtains not meeting the minimum netting size, light fixtures blocking sprinkler spray, elevator equipment room not sprinkler protected per NFPA 13 requirements, and some ceiling tiles with holes or damaged not allowing the quick activation of the sprinkler head in the event of a fire. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect 1/3 of the 530 out-patients that the facility was licensed to serve, as well as an undetermined number of visitors and 18 staff members.
FINDINGS INCLUDE:
Building #5 - On 11/16/2011 at 3:00 pm surveyor #18107 observed in the SC-17 smoke compartment on the 1st floor in the Data Closet, that there was one or more unsealed holes near the ceiling. The holes included several missing ceiling tiles. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not provide a ventilation system in accordance with the manufacturer specifications per NFPA 101 (2000 edition), section 39.5.2 Heating, Ventilating, and Air Conditioning, and NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems 1999 edition. Facility is required to have regular damper maintenance and where present, plenum mechanical rooms free of storage. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect 1/3 of the 530 out-patients that the facility was licensed to serve, as well as an undetermined number of visitors and 18 staff members.
FINDINGS INCLUDE:
Building #5 - On 11/16/2011 at 2:21 pm surveyor #18107 observed in the SC-16 smoke compartment on the Basement floor in the Mechanical & Boiler Room, that during a review of documents and on-site survey tour it was discovered that all required maintenance procedures were not performed. The damper closing mechanism was damaged and dangling from its housing were attached to the fire-rated wall assembly. Since inspections are done in-house, it could not be substantiated the other dampers were reviewed. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with full documentation of monthly generator testing. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/14/2011 at 3:30 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Generator Room, that during a review of facility documents there was no written record indicating the emergency generator was exercised for 30 minutes each month at the appropriate operating temperature, or with a load that exceeded 30% of the nameplate rating or at the minimum exhaust gas temperature. The facility did not provide information from the manufacturer to support their recommended operating temperature or emergency generator exhaust gas temperature requirements. The generator was exercised monthly by in-house hospital maintenance staff without all the required items listed to be tested per NFPA 110 & NFPA 99. Observed missing month of October 2011. There was no signature of who performed the testing and dated, therefore it could not be verified. This observed situation was not compliant with NFPA 110 (1999 edition), 6-4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, fixed wiring rather than extension cords, and electrical panels with complete directories. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 9:22 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Kitchen Food Storage Room, that access to an electrical panel was less than 3'-0" clearance. Electrical breaker panel was blocked by a cart. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 5:26 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Surgery Core Scope Cleaning area, that access to the electrical panels was less than 3'-0" clearance. The electrical panels located in the corridor, aisle or passage area within surgery were blocked by standing un-attended carts for greater than 1/2 hour. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 9:03 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Kitchen, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to two (2) toasters. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and Article 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

4. On 11/15/2011 at 3:10 pm surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the West Corridor of the Hospital (Chapter 19) leading to the Ambulatory Care Center (Chapter 20) - both Type II(111) structures, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #'s for; Normal, Critical & Life Safety - were not labeled correctly. Breaker #'s 82 & 84 were marked as spares but were in the 'ON' position. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

5. On 11/15/2011 at 4:30 pm surveyor #18107 observed in the SC-07 smoke compartment on the 1st floor in the Main Boiler Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #OMB-13, including breakers # LB-1 & #15 - could not determine where the power was going to, since the breakers were in the 'ON' position. Same for Panel #D. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

6. On 40863 at 7:55 am surveyor #18107 observed in the SC-08 smoke compartment on the 1st floor in the Main East-West Corridor, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #1/NC Section 2 was missing blank cover plates at #60, 62 & 64 breaker openings. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and use a program to respond to outages of the sprinkler system with complete procedures for responding to outages. This deficiency occurred in 18 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/14/2011 at 4:30 pm surveyor #18107 observed in the Document Review the smoke compartment on the 1st floor in the Hospital & other attached clinics, that during a review of facility documents the facility did not have a written Fire Watch Policy in the event either the sprinkler system or fire alarm sytem was out for more than 4 hours in a 24 hour period. The facility policy was missing. The facility stated "they would have to create this document." This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide a common separation wall with rated doors, sealed wall penetrations, and rated wall construction. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/15/2011 at 10:33 am surveyor #18107 observed in the SC-03 smoke compartment on the 1st floor in the Separation between the Hospital & the new MOB/ACC at Corridor Connections, that a penetration was not sealed according to an approved method. The deficiency included a mechanical duct penetrating the 2-hour wall assembly and part of the duct was not fire-sealed properly where it penetrated the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide a common separation wall with rated doors, sealed wall penetrations, and rated wall construction. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 12:02 pm surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the Corridor between Hospital & MOB, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. Fire doors would not self-latch. Double doors missing coordinator. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 10:33 am surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the Separation between Hospital & new MOB at Corridor Connections, that penetration(s) were not sealed according to an approved method. The deficiency included a mechanical duct penetrating the 2-hour wall assembly and part of the duct was not fire-sealed properly where it penetrated the wall. This observed situation was not compliant with NFPA 101 (2000 edition), section 19.1.1.4; and section 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/16/2011 at 9:45 am surveyor #18107 observed in the SC-12 smoke compartment on the 1st floor in the Maternity and Infant Unit along the Separation Wall, that the separation wall was not constructed to have a 2-hour fire resistance rating because top of wall was open and not fire sealed as well as screws not double mudded and seams not taped in all places. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing, and support steel covered with rated fire proofing. This deficiency occurred in 7 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients & all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 8:25 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Air Handling Unit #3 Room, that fire proofing was missing from the structural steel beam or steel floor joist system. The ceiling assembly providing the fire protection to the floor assembly was not completed correctly. Screws were not double mudded and drywall seams were not taped. These deficiencies would allow hot gases and heat to penetrate the protection and effect the exposed steel joist flooring system beyond. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 11:30 am surveyor #18107 observed in the SC-13 smoke compartment on the 2nd floor in the Shell Space & Construction Material Storage Room, that fire proofing was missing from the structural steel at roof deck in a 2-Story Building Type II (111) plus steel angles supporting new concrete plank and steel clamps were not fire-protected. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 1:38 pm surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the Public Toilet Rooms, ER Vestibule & West Corridor next to Gift Shop, that fire proofing was missing from the structural steel at floor above ceiling tiles. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


4. On 11/15/2011 at 3:01 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Surgery Large Storage next to Surgery Receiving Room, that fire proofing was missing from the structural steel at floor assembly above ceiling tile. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

5. On 11/15/2011 at 5:00 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Surgery Suite including OR #1, OR #2, Sterile & Equipment Storage, Sterile Processing, Decontamination Room, Minor Procedure Room & Clean Corridor, that fire proofing was missing from the structural steel at roof assembly above ceiling tile. The roof is supported by steel trusses that are protected by a horizontal shaft wall assembly. The shaft wall assembly is not finished, drywall screws are not double-mudded and drywall sheet edges are not taped to the Underwriters Laboratory 'standard' or any standard not available at time of survey. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

6. On 11/16/2011 at 9:55 am surveyor #18107 observed in the SC-12 smoke compartment on the 1st floor in the Maternity Nurses Station and Staff Lounge, that fire proofing was missing from the structural steel at separation wall and was not fire protected to the required 2-hours where it became part of the separation wall to the connector. Steel clamps and steel beams were un-protected at places. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

7. On 11/16/2011 at 1:30 pm surveyor #18107 observed in the SC-18 smoke compartment on the Basement floor in the Mechanical & Air Handling Unit Room under Medical / Surgical Unit, that fire proofing was missing from the structural steel at floor assembly supporting inpatient sleeping rooms above. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

______________________________________

Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing, and support steel covered with rated fire proofing. This deficiency occurred in 7 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 10:16 am surveyor #18107 observed in the SC-03 smoke compartment on the 1st floor of Building #2, in the Separation between the Hospital & new MOB/ACC near Room 144, that fire proofing was missing from the structural steel at floor/ceiling assembly at separation wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2 & 20.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 10:35 am surveyor #18107 observed in the SC-03 smoke compartment on the 1st floor of Building #2, in the Imaging Waiting, Lab Drawing, Medical Record Film Files Storage near separation wall, that fire proofing was missing from the structural steel at floor deck above ceiling. It also included steel clamps, supporting the sprinkler pipes, not fire-protected where attached to steel beams. This observed situation was not compliant with NFPA 101 (2000 edition), 20.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with no combustible material storage. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 2 of the 187 staff that were working.

FINDINGS INCLUDE:
On 11/15/2011 at 7:40 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Corridor, that the corridor space across from one of the two required exit stairways was used for storage, and was not separated by a wall from the corridor. Storage included many combustible items in boxes on shelving units covering an area of 2' x 6'. This quantity of materials was deemed hazardous for storage in a corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 , and 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide corridor separation doors with louver-free corridor doors, and doors that would close when pushed or pulled. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 9:30 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Dietary Office, that the door had a 24" x 24" size louver that did not resist the passage of smoke between the corridor and the room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 5:01 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the OR #1, OR #2, Surgery Sterile Storage, Surgery Sterile Processing & Surgery Decontamination Rooms), that the door to the corridor was held open with a door stop attached to the bottom of the door to prevent it from closing to the adjoining Surgery Clean Corridor or Aisle that is used for 'exit access' within the Surgery Suite, in the event of a fire. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with sealed wall an floor penetrations. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/15/2011 at 7:44 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Data Room, that penetration(s) in a vertical shaft or floor assembly were not sealed according to an approved method. The deficiency included multiple holes in the floor/ceiling assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with sealed wall or floor penetrations. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect all of the 574 out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/15/2011 at 10:17 am surveyor #18107 observed in the SC-03 smoke compartment on the 1st floor in the Imaging North Corridor, that penetrations in a floor assembly were not sealed according to an approved method. The deficiency included a 1/2 inch conduit penetration through floor assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent, and non-egress pathways without exit signs. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect 59 of the 154 staff that were working in the hospital controlled areas.

FINDINGS INCLUDE:
1. On 11/15/2011 at 8:15 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Storage Suite, that the path of egress in the corridor, aisle or passage was not readily apparent and an exit sign was not provided near the exit and was blocked by pipes, along with partial walls and stacked storage items. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 8:55 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Dining Room, that the path of egress in the corridor or aisle was not readily apparent and an exit sign was not provided near the exit access door from the dining room. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/16/2011 at 7:28 am surveyor #18107 observed in the SC-08 smoke compartment on the 1st floor in the Monumental Stairway next to SC-09 (smoke compartment), that an exit sign was installed at a location that the facility confirmed was 'not an exit'. This stairway adjoins a renovated hospital office area. The Basement does not require this 'exit egress' pathway per the revised Life Safety Plan. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/15/2011 at 2:24 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Surgery Women's Locker Room, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the top-of-wall was not sealed correctly. A continuous opening was present at top of wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with compliant smoke doors. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/16/2011 at 8:51 am surveyor #18107 observed in the door straddling the SC-10 & SC-12 smoke compartments on the 1st floor in the Data Closet/ Nurse Call/ TV Cabling, that the smoke barrier door was not compliant. The Data Room door was shown to be in the smoke barrier per the Life Safety Plans. The door has a 24" x 24" Grille/Louver in the door that is not permitted. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not enclose hazardous rooms with closer's on all doors, a smoke-tight room enclosure (in a sprinkled smoke zone), and sealed wall penetrations. This deficiency occurred in 4 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 9:15 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Kitchen Office, that the door would not self-close because it was missing a door closer. Per the Life Safety Plan used as reference during the Survey Tour, this room is shown as a hazardous space. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 2:01 pm surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the ER Soiled Utility Room & Ambulance Garage Room , that penetrations were not sealed according to an approved method. The deficiency included numerous screws, pipes & conduits penetrations. These observed situations were not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 4:42 pm surveyor #18107 observed in the SC-07 smoke compartment on the 1st floor in the Main Boiler Room, that penetrations were not sealed according to an approved method. The deficiency included screws in 2-hour fire-rated wall assembly were not double mudded, not meeting Underwriters Laboratory minimum requirements for this tested assembly and observed three (3) vacuum pipes plus numerous electrical conduit penetrations. These observed situations were not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide egress paths at all times with doors that opened with under 50 pounds of force, paths with sufficient headroom, door hardware that operated with a single release motion, paths that are maintainable in all weather conditions and level walking surfaces in the path of egress. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/16/2011 at 9:08 am surveyor #18107 observed in the SC-12 smoke compartment on the 1st floor in the Maternity & Child Health Corridor, that the door in the path of egress would not open when a force of greater than 50 lbs. pressure was applied to two Corridor egress doors, three Labor / Delivery / Recover (LDR) doors, and two Post Partum doors that exceeded the maximum 50 lbs. needed to open an existing exit access door due to door stops at bottom of these doors. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 7:29 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Corridor, that the headroom was 6'- 6-5/8" at center of corridor from a sprinkler pipe. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.5 headroom. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 8:54 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Dining Room, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a deadbolt to keep the door locked. This dining room can hold over 40 persons at any one time. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

4. On 11/15/2011 at 8:41 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Exit Discharge, that a portion of the path of egress had an abrupt change in elevation of greater than 1/2 inch at the stoop and door threshold. This observed situation was not compliant with NFPA 101 (2000 edition), sections 19.2.1, 7.1.6 and 7.1.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide all spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress with locks that activate within 3 seconds. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/16/2011 at 8:23 am surveyor #18107 observed in the SC-11 smoke compartment on the 1st floor in the Medical /Surgical Unit at the East and West Exit Discharge Doors, that a 'delayed egress lock' (DEL) did not activate within 3 seconds of pushing the release mechanism and the doors took greater than 30 seconds to activate the release of the door upon pushing the horizontal bar continuously for 3 seconds. Signage was missing next to the door or on the door to let persons wanting to leave the building in an emergency that these doors were delayed egress. The facility could not provide documentation showing these exit doors were permitted to be delayed 30 seconds upon activation of the push-bar to open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 8:30 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Exit Discharge, that the path of egress to the public way was not illuminated to at least 1 foot-candle. Facility could not confirm that lighting was on the emergency circuit and the lamps could produce 1 ft. candle along the entire route to a public way. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 8:45 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Dietary Stairwell, that the path of egress to the public way was not illuminated to at least 1 foot-candle. Lighting was missing at the exit discharge. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with the required quantity of drills. This deficiency occurred in 18 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/14/2011 at 4:00 pm surveyor #18107 observed in the Document Review the smoke compartment on the 1st floor in the Hospital & other attached Clinics, that during a review of facility documents the Fire Drill Report showed that fire drills were not conducted quarterly on every shift. Observed through documentation review that the 4th Quarter at 2nd Shift was missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The facility did not provide a fire alarm system with and smoke detectors at required locations. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as 6 hospital staff and visitors.

FINDING INCLUDEs:
On 11/16/2011 at 9:19 am surveyor #18107 observed in the SC-12 smoke compartment on the 1st floor in the Pantry open to the corridor and not visible from the nurses station, that the smoke detector was not located in accordance with NFPA 72 requirements. The smoke detector was missing in an area open to the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 & 9.6.1.4 and NFPA 72 (1999 edition), 2-2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The facility did not provide a sprinkler system with all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 8:20 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Air Handling Unit #3 Room, that the room was not sprinkler protected. A sprinkler head is missing in one of the corners. This observed situation was not compliant with NFPA 101 (2000 edition), section 9.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 9:14 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the AHU #12 Room, that the room was not sprinkler protected. A sprinkler head is missing at top of ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), section 9.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 3:05 pm surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the ER On-Call Shower Room & X-Ray Data Closet, that the room was not sprinkler protected. This observed situation was not compliant with NFPA 101 (2000 edition), section 9.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

4. On 11/16/2011 at 1:35 pm surveyor #18107 observed in the SC-18 smoke compartment on the Basement floor in the Mechanical & Air Handling Unit Room under Medical / Surgical Unit, that the room was not sprinkler protected. Mechanical ducts blocked sprinkler distribution in four (4) portions of the room. This observed situation was not compliant with NFPA 101 (2000 edition), sections 9.7 and 6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

5. On 11/15/2011 at 8:53 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Elevator #2 Equipment Room, that there was no sprinkler or approved alternative suppression measures. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.1 (exception). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

6. On 11/16/2011 at 7:34 am surveyor #18107 observed in the SC-09 smoke compartment on the 1st floor in the Physician On-Call Toilet /Shower Room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a shower curtain. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

7. On 11/16/2011 at 8:27 am surveyor #18107 observed in the SC-11 smoke compartment on the 1st floor in the Room #120 - Toilet / Shower Room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a shower curtain. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

8. On 11/16/2011 at 9:13 am surveyor #18107 observed in the SC-12 smoke compartment on the 1st floor in the Room # 131 - Toilet /Shower, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a shower curtain. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 10 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 9:27 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Kitchen Corridor, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the corridor and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 2:15 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Decontam Shower in Ambulance Garage, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 7:30 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Facility Office, Storage Suite & Record Storage Rooms, that there was one or more unsealed holes near the ceiling. The holes included numerous ceiling tiles missing or with holes in them from pipes, conduits or damaged tiles. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

4. On 11/15/2011 at 11:45 am surveyor #18107 observed in the SC-13 smoke compartment on the 2nd floor in the Shell Space & Construction Material Storage Room, that there was one or more unsealed holes near the ceiling. The holes included numerous openings along top-of-wall to roof deck. These holes would reduce the response time of the sprinklers in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

5. On 11/15/2011 at 2:26 pm surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the X-Ray Communications Closet, General Radiographic Room #1, X-Ray Janitor Closet & X-Ray Data Closet, that there was one or more unsealed holes near the ceiling. The holes included 1" diameter opening at pipe sleeve, 24" x 24" tiles out at two different rooms and 2-sleeves with 2" diameter openings. The Accounting Office Storage Closet had a sprinkler blockage. These holes and penetrations would reduce the response time of the sprinkler in their rooms or spaces and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

6. On 11/15/2011 at 3:33 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Print Room, that there was one or more unsealed holes near the ceiling. The holes included 4 ceiling panels missing. This holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

7. On 11/15/2011 at 3:50 pm surveyor #18107 observed in the SC-08 smoke compartment on the 1st floor in the Medical Records Room, that there was one unsealed hole near the ceiling. The hole included one fire alarm conduit penetration. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

8. On 11/16/2011 at 8:01 am surveyor #18107 observed in the SC-10 smoke compartment on the 1st floor in the Main East-West Corridor, that there was one unsealed hole near the ceiling. The hole included a ceiling tile open along one edge in corridor 1/2" x 24". This hole would reduce the response time of the sprinkler in the corridor and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

9. On 11/16/2011 at 8:53 am surveyor #18107 observed in the SC-12 smoke compartment on the 1st floor in the Data Closet/ Nurse Call/ TV Cabling, that there was one or more unsealed holes near the ceiling. The holes included numerous penetrations from wires in ceiling and parts of ceiling tiles were missing. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with accessible extinguisher. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 11 of the 154 staff that were working.

FINDINGS INCLUDE:
On 11/16/2011 at 7:40 am surveyor #18107 observed in the SC-09 smoke compartment on the 1st floor in the Hospital Biller's Workroom, that a fire extinguisher was not accessible for immediate use because it was blocked by a cart and shelving unit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.6, 9.7.4.1 and NFPA 10 (1998 edition) 1-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A. Facility is required to have regular damper maintenance and where present, plenum mechanical rooms free of storage. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/15/2011 at 8:21 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Air Handling Unit #3 Room, that the mechanical room was used as a plenum for air returning to the air handling unit and was used to store combustibles not used in the operation of the air handling unit per NFPA 90A. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 , 9.2 and NFPA 90A, 2-3.10.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96. Range hoods shall be cleaned semi-annually and extinguisher system shall be clearly identified. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 26 of the 154 staff that were working.

FINDINGS INCLUDE:
1. On 11/14/2011 at 3:00 pm surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Kitchen, that during a review of documents it was discovered that the range hood and ducts were not inspected and cleaned of grease contamination semi-annually, as required for systems serving moderate-volume cooking operations. Cleaning records indicated that only one annual inspection and cleaning were occurring for the kitchen hood and associated exhaust ducts. May 10, 2011 was the last day the kitchen hood was cleaned and inspected. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6; 9.2.3; and NFPA 96 (1998 edition), 8-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 9:05 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Kitchen, that a placard identification sign was not provided above the kitchen hood activation button or above the Type K fire extinguisher to identify their locations. Both were blocked by a kitchen cart. This observed situation was not compliant with NFPA 96 (1998 edition), Section 7-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping. This deficiency occurred in 2 of the 18 smoke compartments and had the potential to affect 10 of the 154 staff that were working.

FINDINGS INCLUDE:
1. On 11/15/2011 at 4:00 pm surveyor #18107 observed in the SC-08 smoke compartment on the 1st floor in the Medical Gas Storage & Manifold Room, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included missing medical gas flow direction via directional signage on the pipe itself. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Chapter 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 4:58 pm surveyor #18107 observed in the SC-07 smoke compartment on the 1st floor in the Main Boiler Room & adjoining Oxygen Storage Room, that medical gas piping was not installed according to the requirements of the Health Care Facilities - Medical Gas & Vacuum Systems Code. The inappropriate piping installation included missing exhaust venting where 'off-gassing' of oxygen is occurring, and missing direction flow signage on vacuum gas piping per section 4-3.2.2.11(h) running through the Main Boiler Room and Oxygen Storage Room. This observed situation was not compliant with NFPA 101 (2000 edition), section 19.3.2.4 and NFPA 99 (1999 edition), Chapter 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not ensure the facility was properly protected from hazardous spaces within its occupancy per NFPA 101 (2000 edition), section 39.1.5. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 23 of the 154 staff that were working in the hospital controlled areas.

FINDINGS INCLUDE:
Building #4 - On 11/16/2011 at 11:16 am surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Materials Management office area, that the room was not sprinkler protected completely along with other hazardous spaces in this area. The floor deck separating the Basement from the MOB above could not be confirmed to be fire-separated from the 1st Floor making it a 2-Story wood frame construction (not sprinkled). Since there is NO fire-separation between 1st Floor (MOB) and Basement (Support to Hospital Functions) due to seams not fire sealed at several locations of floor assembly, and this building was originally built as a 1-Story, Type V (000), the entire Basement and 1st Floor should be sprinkled since there is not separation from a hazardous area. This observed situation was not compliant with NFPA 101 (2000 edition), section 39.1.5 Hazard of Contents, section 6.2 Classification of Occupancy and section 39.1.5.2 where automatic sprinklers are used in a 'business occupancy' shall be classified as a light hazard occupancy in accordance with NFPA 13. Hazardous areas shall be separated from other spaces. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not provide proper protection from hazardous areas with the proper sprinkler system that complies with NFPA 101 (2000 edition), section 39.3.2 Protection from Hazards and section 8.4 Special Hazard Protection. Per section 8.4.1.1(2), area shall be protected with an automatic extinguishing system in accordance with section 9.7. Section 9.7 requires a NFPA 13, Standard for the Installation of Sprinkler Systems Installation. Based on NFPA 13, sprinklers were not free of obstructions near the ceiling and in the interstitial areas between acoustical tile ceiling and floor assembly. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 23 of the 154 staff that were working.

FINDINGS INCLUDE:
1. Building #4 - On 11/16/2011 at 11:14 am surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Materials Management main storage area, that the room was not sprinkler protected. Missing or blocked sprinkler heads above the ceiling through-out the Basement area. Due to sprinkler blockages, this does not meet minimum requirements for a sprinkled area. This observed situation was not compliant with NFPA 101 (2000 edition), sections 9.7 and 6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. Building #4 - On 11/16/2011 at 11:54 am surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Clinical Laboratory - Storage area, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included boxed storage items in close proximity to a sprinkler head. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent, and non-egress pathways without exit signs per NFPA 101 (2000 edition), section 39.2.10 Marking of Means of Egress. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect 59 of the 154 staff that were working in the hospital controlled areas.
FINDINGS INCLUDE:
Building #4 - On 11/16/2011 at 12:05 pm surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Exit Stairway, that the path of egress in the corridor or aisle was not readily apparent and an exit sign was not provided near the exit stairway. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not provide and maintain all exit access stairs with enclosure assemblies free of storage per NFPA 101 (2000 edition), 39.2.1 Means of Egress Requirements & all of Chapter 7 Impediments to Egress. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 23 of the 154 staff that were working.
FINDINGS INCLUDE:
Building #4 - On 11/16/2011 at 12:02 pm surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Exit Stairway, that a portion of the stair enclosure was being used as usable space (storage). The stairs was being used for storage of combustibles at the bottom of the stairs from 1st Floor and from this Basement Floor Level. The code requires that "there shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential of interfere with egress". This observed situation was not compliant with NFPA 101 (2000 edition), 39.2.1 Means of Egress Requirements and 7.2.2.5.3 Usable Space. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not ensure that corridors did not have excessively long dead-ends as permitted by the code with too long of dead-end corridors per NFPA 101 (2000 edition), 39.2.5.2 . This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 23 of the 154 staff that were working.
FINDINGS INCLUDE:
Building #4 - On 11/16/2011 at 11:26 am surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Clinical Laboratory - Histology Lab area, that a dead end corridor, aisle or passage of greater than 50 lineal feet was observed from the far back corridor outside the Histology Lab. The story is not fully-sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 39.2.5.2 for dead-end corridors exceeding 50 feet. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent, and non-egress pathways without exit signs per NFPA 101 (2000 edition), section 39.2.10 Marking of Means of Egress. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect 59 of the 154 staff that were working in the hospital controlled areas.
FINDINGS INCLUDE:
Building #3 - On 11/16/2011 at 11:09 am surveyor #18107 observed in the SC-14 smoke compartment on the 1st floor in the Connector, that the path of egress in the corridor or aisle was not readily apparent and an exit sign was not provided near the exit discharge that lead to the loading dock area, that lead to the public way. An exit directional sign was also missing in the corridor of the connector from the 2nd exit access of Maternity Unit. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with sealed shaft walls and floor penetrations per NFPA 101 (2000 edition), 39.3.1 Protection of Vertical Openings. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect one third of the 530 out-patients that the facility was licensed to serve, as well as 18 staff and an undetermined number of visitors.
FINDINGS INCLUDE:
Building #5 - On 11/15/2011 at 2:45 pm surveyor #18107 observed in the SC-17 smoke compartment on the 1st floor in the West Stairway, that penetrations in the floor assembly were not sealed according to an approved method. The deficiency included three holes near top-of-wall and above the acoustical tile ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not enclose hazardous rooms like boiler or furnace rooms with closer's on all doors per NFPA 101 (2000 edition), 39.3.2.1. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 1/3 of 530 out-patients that the facility was licensed to serve, as well as an undetermined number of visitors and 18 staff members.
FINDINGS INCLUDE:
Building #5 - On 11/16/2011 at 2:20 pm surveyor #18107 observed in the SC-16 smoke compartment on the Basement floor in the Mechanical & Boiler Room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of several unsealed holes. The holes included two holes in walls from either pipes or conduits that were removed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2.1, section 9.7 and 8.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not provide egress paths at all times with doors that opened with under 50 pounds of force, paths with in-sufficient headroom, door hardware that operated with a single release motion, paths that are maintainable in all weather conditions, and level walking surfaces in the path of egress per NFPA 101 (2000 edition), section 39.2.1. General-Means of Egress, 39.2.2.1 Means of Egress Components (Doors), and all of Chapter 7 Means of Egress. This deficiency effected 2 of the 18 smoke compartments, and had the potential to affect 1/3 of the 530 out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.
FINDINGS INCLUDE:
1. Building #5 - On 11/16/2011 at 2:31 pm surveyor #18107 observed in the SC-16 smoke compartment on the Basement floor in the Rehabilitation, Lymphoedema & Support areas, that the door would not open when a maximum 50 lbs. pressure was applied to the doors to open an existing exit access door due to door stops at bottom of these doors. The hardware included door stops attached to the bottom of several doors through-out the area. This observed situation was not compliant with NFPA 101 (2000 edition), sections 39.2.2.2.1 & 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).
2. Building #5 - On 11/16/2011 at 2:50 pm surveyor #18107 observed in the SC-17 smoke compartment on the 1st floor in the Corridor Suite doors, that the door release hardware required more than a single motion to release the door for exiting to the corridor. The suite entrance hardware included dead-bolts. This observed situation was not compliant with NFPA 101 (2000 edition), sections 39.2.2.2.2 and 7.2.1.5.1. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).
3. Building #5 - On 11/16/2011 at 2:37 pm surveyor #18107 observed in the SC-16 smoke compartment on the Basement floor in the South & West Exit Discharges to a Public Way, that the exit discharge path did not have a maintainable surface. The path of egress was composed of grass and mulch. There was no hard surface for rehabilitation patients to a public way from this exit discharge. This observed situation was not compliant with NFPA 101 (2000 edition), sections 39.2.7 and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure per NFPA 101 (2000 edition), section 39.2.9 Emergency Lighting and section 7.9 Emergency Lighting. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect 1/3 of 530 out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.
FINDINGS INCLUDE:
Building #5 - On 11/16/2011 at 2:09 pm surveyor #18107 observed in the SC-16 smoke compartment on the Basement floor in the two Exit Stairways and Exit Discharges, that the facility was unable to verify that the lighting along the path of egress was powered from the emergency electrical system. This observed situation was not compliant with NFPA 101 (2000 edition), 7.9.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not install and maintain a Automatic Sprinkler System according to NFPA 13 requirements per NFPA 101 (2000 edition), Section 9.7. The facility did not provide a sprinkler system with all rooms sprinkled when the facility told me that it was fully-sprinkled. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 1/3 of the 530 out-patients that the facility was licensed to serve, as well as an undetermined number of visitors and 18 staff members.
FINDINGS INCLUDE:
Building #5 - On 11/16/2011 at 1:55 pm surveyor #18107 observed in the SC-16 smoke compartment on the Basement floor in the Rehabilitation and Support areas, that the sprinkler installation was not compliant. The sprinklers were observed in several locations throughout this area to be blocked by cubical curtains not meeting the minimum netting size, light fixtures blocking sprinkler spray, elevator equipment room not sprinkler protected per NFPA 13 requirements, and some ceiling tiles with holes or damaged not allowing the quick activation of the sprinkler head in the event of a fire. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect 1/3 of the 530 out-patients that the facility was licensed to serve, as well as an undetermined number of visitors and 18 staff members.
FINDINGS INCLUDE:
Building #5 - On 11/16/2011 at 3:00 pm surveyor #18107 observed in the SC-17 smoke compartment on the 1st floor in the Data Closet, that there was one or more unsealed holes near the ceiling. The holes included several missing ceiling tiles. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).


Based on observation and interview, the facility did not provide a ventilation system in accordance with the manufacturer specifications per NFPA 101 (2000 edition), section 39.5.2 Heating, Ventilating, and Air Conditioning, and NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems 1999 edition. Facility is required to have regular damper maintenance and where present, plenum mechanical rooms free of storage. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect 1/3 of the 530 out-patients that the facility was licensed to serve, as well as an undetermined number of visitors and 18 staff members.
FINDINGS INCLUDE:
Building #5 - On 11/16/2011 at 2:21 pm surveyor #18107 observed in the SC-16 smoke compartment on the Basement floor in the Mechanical & Boiler Room, that during a review of documents and on-site survey tour it was discovered that all required maintenance procedures were not performed. The damper closing mechanism was damaged and dangling from its housing were attached to the fire-rated wall assembly. Since inspections are done in-house, it could not be substantiated the other dampers were reviewed. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with full documentation of monthly generator testing. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/14/2011 at 3:30 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Generator Room, that during a review of facility documents there was no written record indicating the emergency generator was exercised for 30 minutes each month at the appropriate operating temperature, or with a load that exceeded 30% of the nameplate rating or at the minimum exhaust gas temperature. The facility did not provide information from the manufacturer to support their recommended operating temperature or emergency generator exhaust gas temperature requirements. The generator was exercised monthly by in-house hospital maintenance staff without all the required items listed to be tested per NFPA 110 & NFPA 99. Observed missing month of October 2011. There was no signature of who performed the testing and dated, therefore it could not be verified. This observed situation was not compliant with NFPA 110 (1999 edition), 6-4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, fixed wiring rather than extension cords, and electrical panels with complete directories. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 9:22 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Kitchen Food Storage Room, that access to an electrical panel was less than 3'-0" clearance. Electrical breaker panel was blocked by a cart. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 5:26 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Surgery Core Scope Cleaning area, that access to the electrical panels was less than 3'-0" clearance. The electrical panels located in the corridor, aisle or passage area within surgery were blocked by standing un-attended carts for greater than 1/2 hour. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 9:03 am surveyor #18107 observed in the SC-01 smoke compartment on the Basement floor in the Kitchen, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to two (2) toasters. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and Article 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

4. On 11/15/2011 at 3:10 pm surveyor #18107 observed in the SC-05 smoke compartment on the 1st floor in the West Corridor of the Hospital (Chapter 19) leading to the Ambulatory Care Center (Chapter 20) - both Type II(111) structures, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #'s for; Normal, Critical & Life Safety - were not labeled correctly. Breaker #'s 82 & 84 were marked as spares but were in the 'ON' position. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

5. On 11/15/2011 at 4:30 pm surveyor #18107 observed in the SC-07 smoke compartment on the 1st floor in the Main Boiler Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #OMB-13, including breakers # LB-1 & #15 - could not determine where the power was going to, since the breakers were in the 'ON' position. Same for Panel #D. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

6. On 40863 at 7:55 am surveyor #18107 observed in the SC-08 smoke compartment on the 1st floor in the Main East-West Corridor, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #1/NC Section 2 was missing blank cover plates at #60, 62 & 64 breaker openings. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Based on observation and interview, the facility did not provide and use a program to respond to outages of the sprinkler system with complete procedures for responding to outages. This deficiency occurred in 18 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and all out-patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/14/2011 at 4:30 pm surveyor #18107 observed in the Document Review the smoke compartment on the 1st floor in the Hospital & other attached clinics, that during a review of facility documents the facility did not have a written Fire Watch Policy in the event either the sprinkler system or fire alarm sytem was out for more than 4 hours in a 24 hour period. The facility policy was missing. The facility stated "they would have to create this document." This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facility Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).