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Based on observation during the survey walk-through, vertical openings between floors are not protected. These deficiencies could result in the effects of fire and smoke on one floor level transferring to another floor level and compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:

On 12/01/15 at 4:30pm while in the company of DCC & LSS, it was observed that the basement level under the adjacent tenant space which is accessed from the Illini Xpress Clinic was not separated from the crawl space of the first floor Illini Xpress Clinic tenant space and the first floor Illini Xpress Clinic tenant space to comply with 38.3.1.1 and 8.2.5. The basement area is utilized for incidental storage and gas fired furnace/water heater equipment and lacks minimum 1-hour separation from the first floor Illini Xpress Clinic tenant space both at the wall of the crawl space (where piping, etc. extends) and at the stair wall/door which separates the basement from the first floor. These conditions do not comply with 38.3.1.2, 8.2.5.4 and 8.2.5.7. (See K029 also)

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's means of egress.

Findings include:

On 12/01/15 at 4:15pm while in the company of DCC & LSS, the surveyor observed that the fuel fired furnace & water heater units located in the basement which is accessed from the Illini Xpress Clinic tenant space and the furnace unit above the finished ceiling of the Illini Xpress Clinic tenant space breakroom were not protected to comply with 38.3.2.1 and 8.4.1.1. The spaces are neither sprinklered or separated by 1-hour rated construction. (See K020 also)

Based on observation and staff interview during the survey walk-through, fire alarm systems are not installed as required. This deficiency could affect any patients, staff, or visitors in the building because the lack of a fire alarm system can delay awareness and response to fire emergencies.

On 12/01/15 at 4:30pm while in the company of DCC & LSS, the surveyor observed and was informed by staff that this 3-story building is not provided with a fire alarm system to comply with 38.3.4.1(1) and 9.6. Only single station smoke alarms are provided at select locations within the tenant space.

Based on observation during the survey walk-through, while accompanied by facility staff, the sprinkler installation does not comply. Failure to install and maintain the sprinkler system could result in failure or delayed response of the sprinkler system to control a fire event, which could affect patients, staff and visitors.
Findings include:
A. Corrected 4/18/16.

B. On 12/01/15 at 2:00pm while in the company of DCC & LSS, the surveyor observed that the 1st floor north air handler room is provided with sprinkler protection but is not separated from the adjacent non-sprinklered above-ceiling space of the remainder of the suite to comply with NFPA 13-1999. This lack of containment of the room will delay the activation of the sprinkler protection.

Based on observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.