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Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with LSC Sections 18.3.7.3 and 18.3.7.5. This deficient practice could potentially affect approximately 3 occupants of the facility in the event of smoke not being contained to the compartment of origin.

Findings Include:
On 8/6/15 at approximately 11:36am, two unprotected conduit penetrations were observed in the smoke barrier wall adjacent to the Birthing Suites entrance doors. The penetrations consisted of blue and green wires that were sleeved in conduit.

On 8/6/15 at approximately 11:37am during an interview of Maintenance #2, he was unaware of the penetrations and that they were data cables.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with LSC Section 18.3.2.1. This deficient practice could potentially affect approximately 5 occupants of the facility in the event of a fire not being contained to the hazardous area.

Findings Include:
On 8/6/15 at approximately 10:47am, Procedure Rooms 2 and 3 were observed to have paper signs affixed to the wall stating "Storage". Upon opening the room doors, large amounts of materials and equipment were observed in the rooms. The doors to the rooms were not labeled 45-minute fire doors and the rooms were not verified to be protected by 1-hour fire-rated walls.

On 8/6/15 at approximately 10:48am, in an interview with Maint #1, he stated that he was unaware that the space had been converted to storage use.

Based on review of records and interview, the facility failed to provide an approved written plan for the protection of all patients and for their evacuation in the event of an emergency in accordance with LSC Section 18.7.1.1. This deficient practice could potentially affect all occupants of the facility in the event of a fire emergency.

Findings Include:
On 8/6/15 between 9:00am and 9:40am during records review, the facility Fire Emergency Plan did not contain information on the use of a code phrase when an individual mist immediately go to the aid of an endangered person or during the malfunction of the fire alarm system in accordance with Section 18.7.2.3.

On 8/6/15 at approximately 9:25am, in an interview with Maint #2, he stated the plans were under revision and provided a proposed plan that did not have the code phrase information either.

Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with LSC Sections 18.3.7.3 and 18.3.7.5. This deficient practice could potentially affect approximately 3 occupants of the facility in the event of smoke not being contained to the compartment of origin.

Findings Include:
On 8/6/15 at approximately 11:36am, two unprotected conduit penetrations were observed in the smoke barrier wall adjacent to the Birthing Suites entrance doors. The penetrations consisted of blue and green wires that were sleeved in conduit.

On 8/6/15 at approximately 11:37am during an interview of Maintenance #2, he was unaware of the penetrations and that they were data cables.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with LSC Section 18.3.2.1. This deficient practice could potentially affect approximately 5 occupants of the facility in the event of a fire not being contained to the hazardous area.

Findings Include:
On 8/6/15 at approximately 10:47am, Procedure Rooms 2 and 3 were observed to have paper signs affixed to the wall stating "Storage". Upon opening the room doors, large amounts of materials and equipment were observed in the rooms. The doors to the rooms were not labeled 45-minute fire doors and the rooms were not verified to be protected by 1-hour fire-rated walls.

On 8/6/15 at approximately 10:48am, in an interview with Maint #1, he stated that he was unaware that the space had been converted to storage use.

Based on review of records and interview, the facility failed to provide an approved written plan for the protection of all patients and for their evacuation in the event of an emergency in accordance with LSC Section 18.7.1.1. This deficient practice could potentially affect all occupants of the facility in the event of a fire emergency.

Findings Include:
On 8/6/15 between 9:00am and 9:40am during records review, the facility Fire Emergency Plan did not contain information on the use of a code phrase when an individual mist immediately go to the aid of an endangered person or during the malfunction of the fire alarm system in accordance with Section 18.7.2.3.

On 8/6/15 at approximately 9:25am, in an interview with Maint #2, he stated the plans were under revision and provided a proposed plan that did not have the code phrase information either.