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Based upon observation, the Non-Health Care Business occupancy MOB is not completely separated from the Hospital Health Care occupancy in accordance with Code requirements. Failure to properly separate the occupancies can result in exposing the Health Care occupancy to hazardous conditions originating within the Business occupancy.

Findings include:

On March 4, 2020 at 3:00pm while in the company of the DF, E, & RFM, it was observed above the ceiling at the cross corridor doors accessing the MOB that a complete fire rated joint assembly extending to the roof deck of the MOB did not appear to be present because exposed mineral fiber/fiberglas backing material was observed not to be covered by intumescent spray as described by the UL tested design assembly identified to comply with 19.1.3.4.1 and 8.3.1.2.

Based upon observation, cooking facilities and storage locations are not separated from corridors to comply with Code requirements. Failure to properly separate cooking & storage uses from the corridor can compromise the use of the corridor in the event of a fire/smoke condition originating from the Kitchen/Storage room.

Findings include:

On March 4, 2020 at 4:10 pm while in the company of the DF, E & RFM, it was observed that a room used for the storage of can goods and combustibles was open to the Kitchen and the Kitchen/Servery corridor doors had the closers disconnected. The storage function constitutes a hazardous area open to the Kitchen which requires the Kitchen to be classified as hazardous. The doors at the Servery/Dining room form the boundary of the area and the separation from the corridor, (Dining is open to the corridor). The doors are not self closing to comply with 19.3.2.1 & 19.3.2.5.

Based on observation, not all corridor doors are installed and maintained as required. Failure to maintain corridor doors in accordance with Code requirements could affect patients, staff, and visitors in the area because smoke or fire could move from the separated rooms to the corridor if the doors are not properly installed and maintained.

Findings include:

On March 4, 2020 at 3:10 pm while in the company of the DF, E, & RFM, it was observed that the Rehab Services corridor door was equipped with an automatic door operator and did not latch to comply with 19.3.6.3.5. Staff indicated that the operator was also not arranged to cease operation during fire alarm activation to comply with 7.2.1.9(4).

Based upon observation, portable unit heaters are in use within the Hospital which could not be confirmed to meet Code requirements. Failure to confirm compliance of heaters can result in an undue fire hazard to patients, staff and visitor occupants of the area of use.

Findings include:

On March 4, 2020 at 3:15 pm while in the company of the DF, E, & RFM, it was observed that an electric portable heater was being used at the Rehab Services office/reception desk which is open to the patient use area. Both requirements of 19.7.8 are not met (devices used only in nonsleeping staff and employee areas and heating elements do not exceed 212 degrees F).

Based upon observation, the buildings Essential Electrical System (EES) is not maintained as a Type 1 system providing separate branches for Life Safety, Critical & Equipment loads. Failure to separate loads on proper branch panels can result in failure of individual panels intended to remain operational for evacuation.

Findings include:

A. On March 4, 2020 at 3:45 pm while in the company of the DF, E, & RFM, it was observed that Life Safety panel LS-2 in the Patient room wing served circuits identified as "power", "Recept A IT", "Power B IT", "Dry Pump Canopy", & "Flag Pole Lights" which may not be permitted on the Life Safety branch of the EES unless serving one of the functions permitted by NFPA 99-2012, 6.4.2.2.3.2. (IT receptacles cannot be on the Life Safety branch unless serving as part of the buildings emergency communication system used for issuing instructions during emergency conditions. General convenience receptacles are otherwise limited to those located at the generator set location. The MRI preaction system is permitted since it is an auxiliary function of the fire alarm system activation but the Canopy dry pipe compressor functions independently prior to the fire alarm system activation.)

B. On March 4, 2020 at 2:45 pm while in the company of the DF, E, RFM, it was observed that Life Safety panel LS1-A may be serving circuits not permitted to be on the Life Safety branch of the EES. Circuits identified as serving "125A feed out to UPS to LS1-B-IT" could not be determined to supply power to functions permitted by NFPA 99-2012, 6.4.2.2.3.2 if serving IT loads not associated with the building emergency communication system.