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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Findings include:

A. Use areas are not separated from exit access corridors or otherwise protected in accordance with the Exceptions granted under 19.3.6.1. Locations and conditions observed include:

1. The 1st floor Emergency Dept. Triage rooms appeared to include patient treatment. the rooms were not separated from the exit access corridor to comply with 19.3.6.1 Exception No. 1, (a).

2. The Emergency Dept. waiting room north vending area was not provided with smoke detection to comply with 19.3.6.1 Exception No. 2, (b).

3. The 2nd floor Maternal/Fetal Medical Clinic waiting area is not provided with smoke detection to comply with 19.3.6.1 Exception No. 2, (b).

4. The "LDRP Unit" reception desk was not provided with smoke detection to comply with 19.3.6.1 Exception No. 1, (c).


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B. Building B First Floor Waiting Room T1077 was observed to lack a smoke detector required by Subpart (b) to Exception 2. of 19.3.6.1.

A. Corridor doors were not provided with positive latching hardware to comply with 19.3.6.3.2. Locations/conditions observed include:

1. The 1st floor corridor door 1-207at the Pacs Reading room suite is equipped with a magnetic locking device which secured the door. The mechanical latch did not engage to comply with 19.3.6.3.2 when the magnetic lock system was released to comply with 7.2.1.6.2. It was not confirmed that the door latch and the magnet lock were tied together to allow the lock to disengage under power loss or fire alarm activation and the door to remain latched.

2. Pairs of corridor doors equipped with power openers and magnetic locking devices were not confirmed to be provided with positive latching hardware upon activation of the fire alarm system and/or loss of power. Under normal operation, the magnetic locking devices appeared to be providing the means by which the doors were being kept closed to comply with the separation of hazardous areas. Locations/conditions observed include but are not necessarily limited to the following:

a. At the Lower Level Housekeeping Storage room across from Care Management offices, it was not clear how latching hardware was provided.

b. At multiple storage room doors along the Lower Level corrdior serving Central Sterile Processing during activation of the fire alarm system, the magnets released, the openers ceased operation, and the mechanical latching hardware was allowed to engage. However, one of the two doors of the pairs did not remain latched at several locations.

c. At the 3rd floor OR Elevator Lobby (T3049) which is designated as a hazardous area and utilized as a storage room, the pair of doors did not have mechanical latching hardware which is required when the magnets are required to release under fire alarm activation/loss of power.

Based on random observation during the survey walk through, not all shafts are constructed or maintained as fire resistive assemblies in accordance with 18.3.1.1.

Findings include:

A. Building C, lower level, Outside EVS staff lounge is a 90 minute rated access door into a shaft which contains the main sanitary stack / tube system / etc. The access door was installed in a cut block opening. The facility could not verify the UL rated design for this installation.


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Based on random observation during the survey walk-through, not all shafts are constructed in accordance with 19.3.1.1.

Findings include:

A. Vertical openings between floors are not protected in accordance with 19.3.1.1 and 8.2.3.2.4. Locations/conditions observed include but are not necessarily limited to the following:

1. 4th Floor Rubbish Chute room (located between the former ICU suites) contained a floor penetration that did not appear to be sealed in accordance with a (UL) tested design.

2. 3rd Floor Men's Toilet room (T3018 adjacent EEG suite?) floor sleeve penetration for heating system piping could not be confirmed to be sealed. This condition of sleeved piping for heating piping existed throughout where visibility of the method of sealing the penetration was not readily observable.

3. 3rd Floor IT closet (T3020 accessed from former Family Waiting) contained unsealed floor penetrations.

4. 3rd Floor Surgery area Electrical room (3123) contained a 4" conduit which appeared not to be sealed.

5. 2nd Floor Telecom room (T2134) contained unsealed floor penetrations.

6. 1st Floor Telecom room (1-210) had what appeared to be a capped/abandoned 10"x10" duct penetration thru the floor above in which duct liner was visible. It was not clear how the 2-hour floor rating was maintained.

7. The dumbwaiter (1267) serving the 1st Floor and Lower Level at the current 1st Floor unoccuppied office area could not be confirmed to maintain the required rating. The shaft enclosure and the shaft access doors could not be confirmed to be minimum 1-hour fire rated assemblies.

8. Lower Level AHU-9 room contained a multi-conduit penetration near the north wall which did not appear to be sealed.

9. Lower Level Mechanical room (0101? containing a fire pump at the west end) was observed with PVC piping penetrations through the floor above which could not be confirmed to be protected in accordance with (UL) tested design assemblies to maintain the 2-hour floor rating.

10. The Lower Level 2-hour rated enclosure between the Morgue and the Biomed Lab was observed with an unrated access panel. The enclosure also contained numerous electrical pull-boxes without covers.

11. The Lower Level Housekeeping Storage room (TB237?) contained copper pipe pentration through the floor which could not be confirmed to be sealed.

12. The Lower Level Electric/Storage room (TB290) contained multiple penetrations through the floor above which could not be confirmed to be sealed.

13. The Lower Level Tool/Equipment Storage room (TB195) contained an electrical pull-box at the ceiling without a cover and several open conduits.

Based on random observation durint the fire alarm testing, it was observed that not all cross corridor fire / smoke doors closed to the latched position.

Findings include:

A. Building "L", 7th floor, 90 minute rated cross corridor doors by room 7006, left leaf did not latch in 2 of 2 attempts.

Based on random observation during the survey walk-through, not all smoke barriers are constructed in accordance with 19.3.7.

Findings include:

A. The 4" conduit sleeve at the cross-corridor doors (S-0465-C) near the 4th floor Vascular Lab 1 was not sealed to maintain the required smoke barrier construction.

Based on random observation during the survey walk-through, not all door openings in smoke barrier walls are constructed or maintained in accordacne with 19.3.7.

Findings include:

A. The corridor door at the 4th floor Vascular Lab 1 is located in a designated smoke barrier wall and was not self-closing to comply with 8.3.4.3. This arrangement does not comply with 19.2.4.3 when the room has its only exit access through the smoke barrier.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 18.3.2.1.

Findings include:

A. "L" Building, 8th floor, Soiled utility (H071), the construction of the back wall is not clear. It appears that a metal stud and gypsum wall board wall was installed in front of a 2 hour rated wall. The 2 hour rated wall only runs about half the length of the soiled utility room. The connection between these two walls was not clear, and it could not be determined that the minimum of 1 hour rating is maintained at the connecting point of these two wall types. The metal stud framing located in front of the 2 hour rated wall is exposed above the ceiling.

B. "L" Building, 3rd floor, Equipment storage (C006), the facilities master plan indicates that the walls are to be 1 hour rated. The wall is stenciled and to be protected to two hour rating. The information provided was conflicting.

C. "L" Building, 2nd floor, Nourishment (B058) the wall is stenciled to maintain 2 hour fire rating. Unsealed sleeves and wall penetrations were observed.


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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

A. Hazardous areas are not separated from adjacent spaces in accordance with 19.3.2.1. Sprinklered hazardous areas are not enclosed including self-closing doors. Locations/conditions observed include:

1. The 3rd floor OR suite containing Clean Utility (3122) has a south door which is not positive latching.

2. The 2nd floor Janitor closet adjacent the LDRP OR Locker rooms contained stored materials. The door was not self-closing.

3. The 1st floor Emergency Dept. Janitor closet (1-162) contained stored materials. The door was not self-closing.

4. The 1st floor Cancer Center "front office" contained rolling files deemed to constitute a degree of hazard greater than that normal to the general occupancy. The door to this space was not self-closing and an unprotected pass-thru window existed to the exit access aisle.

5. The Lower Level door at the Environmental Services Equipment room was not positive latching upon self-closing.


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B. The door to Building F Second Floor File Room T2266 was observed to be held open by an unapproved device (a cardboard box) as prohibited by 19.3.2.1. and 8.2.3.2.3.1(2).

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 38.3.2.1.

Findings include:

A. Soiled Utility Room, door is not self-closing as required for a hazardous area.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. The access door located in Stair #11 at the 3rd floor (T3017) was not confirmed to be installed to maintain the 1 1/2-hour fire rating due to the presence of wood blocking at the frame which was visible from the stair side of the access door.


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B. Fire rated exit passageways were observed at which utilities unrelated to the enclosure (data cables) have been installed as prohibited by 7.1.3.2.1(e). Locations observed include (all First Floor Building B):

1. Exit Passageway for Exit Stair 4.

2. Exit Passageway for Exit Stair 7.

C. Doors to normally unoccupied rooms were observed in fire rated exit enclosures as prohibited by 7.1.3.2.1(d). Locations observed include:

1. Building A Lower Level landing of Exit Stair 3, door to Store Room TB063.

2. Building B First Floor Exit Passageway for Exit Stair 4, door to Store Room T1029.

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2.

Findings include:

A. "L" building, Stairwell doors (all levels, all floors), the hardware installed was not labeled to verify compliance with the 1 1/2 hour rating required by NFPA 80 (1995) 2-8.2.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. The 4th floor Mechanical room above Surgery has a 4" curb at the threshold of the west stair door and the adjacent elevator machine room door in non-compliance with 7.2.1.3.

B. The 3rd floor access to the northeast Stair requires passage through a corridor area constructed as a room which is being used for miscellaneous equipment and cover gowning apparrel. The minimum 8'-0" clear width is not maintained to the stair door and the door between the corridor and the corridor being utilized as a room is not a minimum 41.5" clear width.

C. The 2nd floor Medical Library west exit to the stair has a step at the door in non-compliance with 7.2.1.3.

D. The 1st floor Emergency Dept. Lobby entrance has a revolving door marked as an exit. Conditions observed include:

1. The revolving door does not have an adjacent complying swinging door within a minimum 20' to comply with 7.2.1.10.1(e) Exception No. 2.

2. It was not confirmed that the revolving door complies with 7.2.1.10.2 regarding this door being utilized as a component of the required means of egress.

E. The 1st floor Cancer Center Supply closet is equipped with both a lever handle latch-set and a combination lock/knob-set. The combination lock-set is mounted above the original lever-handle latch-set. The original lever-handle latch-set has been rendered non-functional but its presence on the door can confuse egress since the combination lock-set is at non-standard height and is actually the functional hardware. The appearance of more than one operation to open the door is present and non-compliant with 7.2.1.5.4.

F. Dead bolt locks used in combination with door latch-sets can require more than one operation to open the door in non-compliance with 7.2.1.5.4. Locations observed include but may not necessarily be limited to the following:

1. Three office rooms at the 2nd floor Medical Library.

2. 1st floor Ultrasound rooms 1-254 & 1-253.

3. 1st floor CT Scan rooms 1-314 & 1-315.

G. Doors are equipped with magnetic locking devices which do not comply with all the requirements of 7.2.1.6.2, Access Controlled Egress Doors with particular reference to 7.2.1.6.2(c) regarding the manual release. Locations observed include but are not necessarily limited to the following:

1. 2nd floor Neonatal Nursery west corridor door lacked manual release.

2. 2nd floor east exit from the Medical Library lacked manual release.

3. 1st floor Nuclear Med suite south corridor door required the use of the manual release. The sensor required by 7.2.1.6.2(a) appeared not to be operational.

4. Lower Level door at Housekeeping Storage across from Care Management office lacked manual release.


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H. Most doors to Exit Stairs within Building B (including Exit Stairs 4, 5, 6, and 7) were observed to be equipped with locking devices that are capable of preventing re-entry to the building in a manner prohibited by 7.2.1.5.2.

I. The Building B Sub-Basement was observed was observed to lack at least 1 exit stair which discharges directly to the exterior of the building as required by 7.7.2.

J. Cross-corridor doors identified with signage as exit paths were observed to be locked to prevent egress as prohibited by 7.2.1.5.1. Locations observed include (all Second Floor):

1. Pair of doors at east end of Building B Corridor T2140 (doors to Adult Psychiatric Unit)

2. Pair of doors at north end of Building F Corridor T2177 (doors to Pediatric Psychiatric Unit).

K. Two delayed egress locks were observed, in the egress path from Building B Fifth Floor Corridor T5015 to Exit Stair 6, as prohibited by Exception 2. to 19.2.2.2.4.

Based on random observation during the survey walk through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 18.2.10.1 and 7.10.

Findings include:

A. "L", 1st floor, elevator lobby of Administrative suite, did not contain an exit sign identifying which door is the egress path.


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Based on random observation during the survey walk through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1 and 7.10.

Findings include:

A. Exit and directional exit signage was not provided to clearly identify the required means of egress to comply with 19.2.5.9 and 19.2.10. Locations/conditions observed include:

1. Exit signage is blocked by other signage in the 3rd floor corridor serving the "Holter Pulmonary" suite.

2. Exit signage to the north to provide two separate paths of travel is not provided in the 3rd floor corridor serving the Endoscopy rooms.

3. Exit signage is not provided on the south side of the 2nd floor cross-corrdior doors near the "rear" door to the Neonatal Special Care Nursery suite to identify two separate exit travel paths.

4. An exit sign in the Lower Level mechanical fan room serving the Cancer Care Center was not illuminated.

5. Directional exit signage was observed on the east side of the cross-corridor doors near Elevators #11 & #12 where non-directional signage is appropriate.

6. Exit signage to identify two separate paths of travel to and exit was not provided within the 1st floor Emergency Dept. suite containing "Nurse Station T1440".

7. Exit signage to identify two separate paths of travel within the 1st floor corridor serving the Pacs Reading rooms was not provided.

8. Exit signage to identify two separate paths of travel within the 1st floor corridor serving the Ultrasound rooms #3 & #4 was not provided.

9. Exit signage to identify two separate paths of travel within 1st floor Corridor 1401 was not provided.

10. Exit signage to identify separate paths of travel in the corridor sections east of the Emergency Dept. was not provided (both sides of two sets of double egress cross-corrdior doors).

11. Exit signage at the 1st floor Cancer Care Center north door is obstructed by other signage.

12. Exit signage to identify two separate paths of travel within the 1st floor corridor serving the CT Scan rooms was not provided.

13. Directional exit signage is provided at the 1st floor corridor directing occupant through the MRI area. It is not clear why exiting is directed through this area when other paths appear to be provided. This path requires the traversing of an unenclosed stair which accesses the MRI are which is a half-level floor level change below the remainder of the 1st floor. The MRI corridor is obstructed by a belt stretched across the corridor path to limit normal traffic from gaining close access to the MRI rooms.

14. Exit signage to identify two separate paths of travel within the Lower Level corridor serving the Central Supply room and other Storage rooms was not provided and was obstructed by other signage.

15. Exit signage at the west door within the Lower Level Mechanical room containing the fire pump which accesses the corridor serving the LDRP OR elevators is mounted flat on the wall where a sign perpendicular to the wall is required to allow it to be visible remote from the door.

Based on random observation during the survey walk through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 39.2.10.1 and 7.10.

Findings include:

A. Exit corridor is approximately 214' in length. The corridor only contains two exit signs, one at each end of the corridor. The distance between these exit signs exceeds the 100' maximum allowed 7.10.1.4.

B
ased on direct observation during the survey walk through not all smoke detectors were installed in accordance with NFPA 72.

Findings include:

A. "L" building, 1st floor, Coffee Shop, the smoke detectors are located in the airflow and may prevent operation of the detectors. NFPA 72, 2-3.5.1.

B. "L" building, Lower Level, during the fire alarm test the cross corridor doors by the lab did not release. The magnetic hold open devices were not equipped with a smoke detector on either side of the doors to comply with NFPA 72, 2-10.6.

Based on random observation during the survey walk through, not al portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13, 1999.

Findings include:

A. Rooms and spaces were observed at which sprinkler layout was observed to not provide complete coverage as specified by NFPA 13, 1999. Locations observed include:

1. Lobby, the sprinklers are locate under the soffits at the perimeter of the room. The center of the room contains a raised ceiling and a large shelving unit which is not provided with any sprinkler coverage.

Based on random observation during the survey walk through, not al portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13, 1999.

Findings include:

A. Rooms and spaces were observed at which ceiling tile were observed to be missing or contained penetrations, which compromises sprinkler coverage as prohibited by NFPA 13, 1999, 5-6.4.1.1 and 5-7.4.1.1. Locations observed include:

1. "L" building, 1st floor, AV control room (A017) several ceiling tiles were missing, or not installed in the ceiling track.

2. "C" building, Lower Level, several damaged ceiling tiles were observed in the kitchen. They include broken tiles and damaged tiles which may compromise the sprinkler system.

B. Rooms and spaces were observed at which sprinkler heads were observed collecting a visible accumulation of dust and dirt. NFPA 25, 1995, 2-2.1.1 Locations observed include:

1. "C" building, Lower Level, Kitchen, at the food service line.


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C. Installed sprinkler systems are not in compliance with NFPA 13. Locations and conditions observed include:

1. Sprinkler piping observed in the 4th floor Vascular Lab appeared to have an unsupported length greater than that allowed under NFPA 13, 1999, 6-2.3.

2. The sprinkler head located in the 3rd floor OR Environmental Services closet appeared tobe obstructed by the light fixture.

3. The small L-shaped closet within the 3rd floor CVOR Supply room did not have a ceiling which left the space open to the ceiling cavity of the adjacent Supply room. The size of the ceiling cavity was not determined at the time of the survey and it was not confirmed if other sprinklers existed above the lay-in ceiling of the adjacent Supply room.

4. The shelving installed in the 2nd floor Storage room (T2208) obstructed the sprinkler head.

5. The sprinkler head located in the 2nd floor (Data) Storage room (T2135) was obstructed by shelving/materials less than 18" clearance below the head in non-compliance with NFPA 13, 1999, 5-5.5.2.1.

6. The sprinkler head located near the northwest corner of the Lower Level Film Storage room (TB174) was obstructed by shelving/material less than 18" clearance below the head in non-compliance with NFPA 13, 1999, 5-5.5.2.1.

7. The Lower Level room(s) housing Electric Substation No. 6 are not fully sprinklered. The room is indicated to have a 2-hour separation but not all ducts appeared to be provided with fire dampers to comply with NFPA 13, 1999, 5-13.11 Exception for electrical rooms.

8. The sprinkler heads located in the Lower Level Respiratory Care Educator's Office were less than 6'-0" apart in non-compliance with NFPA 13, 1999, 5-6.3.4. It was noted that an accordian door whci previously existed had been removed.

9. A sprinkler head located in the Lower Level Elevtric/Storage room (TB290) was installed in the pendant position while others in the room were installed in the up-right position. Compliance with NFPA 13, 1999, 5-6.4.1.


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D. Vacated Laboratory Room T1143 was observed to lack a ceiling system, and the interstitial spaces above the ceilings in all spaces directly to the east of that room were observed to be open to Room T1143. Sprinkler coverage for that portion of the building was thus observed to be compromised as prohibited by NFPA 13 1999 5-6.4.1.1.


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By direct observation and staff interview the surveyor finds the facility failed to provide:

A Fire suppression for the following areas:

1. Will County Radio Room

2. Joliet City Radio Room

3. D Building emergency switchgear room

4. Elevator 13 machine room

5. 5th Floor Building B service elevator machine room

6. Electrical room by Medical Word Processing

B. Electronic supervision of all fire sprinkler water supply valves. Valve located in the Lower Level B Building, as observed through the glass ceiling inspection panels, are chained and padlocked but not electronically supervised by the fire alarm system.

Based on random observation during the survey walk through, not al portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13, 1999.
Findings include:

A Rooms and spaces were observed at which sprinkler escutcheon rings were observed to be missing as prohibited by NFPA 13, 1999. Locations observed include:

1. Biohazard Room.

B. Rooms and spaces were observed at which ceiling tile were observed to be missing or contained penetrations, which compromises sprinkler coverage as prohibited by NFPA 13, 1999, 5-6.4.1.1 and 5-7.4.1.1. Locations observed include:

1. Storage room behind the nursing desk, the ceiling tiles were over cut creating a large gap around the wire bundle penetration.

Based on random observation during the survey walk through not all portable fire extinguishers in the facility are installed and maintained in accordance with 18.3.5.6, 9.7.4.1 and NFPA 10.

Findings include:

A. "L" building, all floors, the fire extinguishers are installed at the ends of the corridor in a seating area across from the exit stairs. The cabinets are not readily accessible or immediately available in the event of a fire as required by NFPA 10, 1-6 due to the furniture placement in these areas.

Based on random observation during the survey walk-through and document review, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A.

Findings include:

A. A series of shafts housing toilet exhaust ducts were observed, throughout Building B, which do not carry a minimum 2 hour fire resistance rating required by NFPA 90A 1999 3-3.4.1. Surveyor 14290 notes that, according to the provider's Life Safety Drawings, there appear to be 18 such shafts and that they appear to communicate with the Ninth through Second Floors.

B. The door to Mechanical Room T4178, which constitutes a ventilation shaft at least 4 stories in height, was observed to lack a minimum 1-1/2 hour fire rating required by 8.2.3.2.3.1(1) and NFPA 90A 1999 3-3.4.1.

C. The door to Mechanical Room T2174, which constitutes a ventilation shaft at least 4 stories in height, was observed to not be self-closing as required by 8.2.3.2.3.1(1) and NFPA 90A 1999 3-3.4.1.



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By direct observation the facility failed to provide:

A. Fire dampers for the floor duct penetrations of supply and return/exhaust ventilation systems originating in the 5th floor C Building mechanical room. (NFPA 90A, 1999, 3-3.2)

B. Fire dampers for the duct penetrations through the north wall of the duct shaft (T2174) 2nd floor B Building. (NFPA 90A, 1999, 3-3-4.4)

Based on document review and staff interview, not all portions of the facility's commercial cooking equipment is installed and maintained in accordance with NFPA 96.

Findings include:

A. During the document review process it could not be determined whether the Kitchen hood exhaust ductwork is periodically inspcted for cleaning, as required by NFPA 96 1998 8-3.1., because no records of such cleaning were available. During an interview held in the Facilities Conference Room on the afternoon of may 25, 2010, the provider's Director of Safety and Security confirmed this observation.

Based on random observation during the survey walk through, not all linen or refuse chutes are constructed and maintained as fire resistive assemblies.

Findings include:

A. "L" building, 7th floor, (G060), the waste and linen chutes that are 4 or more stories in height were observed that are not constructed as 2 hour fire rated assemblies as required by 8.2.5.4.(1) and NFPA 82 (1996) 3-2.3 because the latching hardware was not functioning and/or missing.


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B. Lower Level Linen Chute discharge room (TB125? adjacent Central Supply) contained a duct penetration in the corridor wall which could not be confirmed to contain a fire damper.

Based on random observation during the survey walk through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 18.2.3.3 and 7.1.10.2.1. Findings include:

A. "L" building, 8th Floor, ICU contains nursing stations located in niches between patient rooms. The chairs located at each nursing station were found to be unoccupied, and left in the exit path.

B. "L" building, 7th Floor, ICU contains nursing stations located in niches between patient rooms. The chairs located at each nursing station were found to be unoccupied, and left in the exit path.

C. "L" building, Lower Level, Exit path to the dirty dock contains large containers of carboard trash.



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Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. Means of egress corridors are not maintained free of obstructions to comply with 7.1.10. Locations/conditions observed include:

1. The 3rd floor Surgery Dept. is a combination of suites and exit access corridors. The exit access corridors are utilized for storage of equipment/stretchers/carts used in the ORs. The full width of the corridors are not available for full instant use. Although alcove spaces are provided, the amount of equipment stationed open to the corridors exceeds the available space of the alcoves.


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B. Chairs or stools were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. Building B:

a. Fourth Floor:

1. Corridor T4243.

2. Corridor T4275

3. Corridor T4300.

b. Third Floor:

1. Corridor T3143.

2. Corridor T3153.

3. Corridor T3125.

2. Building F Second Floor Corridor T2177.

Based on random observation during the survey walk through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. "L" building, 7th floor, Equipment Storage (G075), contained eight oxygen tanks that were not provided with a minimum of 5'-0"separation from the stored materials in this room based on NFPA 99 (1999) 8-3.1.11.2(c)(2).

B. "L" building, Lower Level, Medical Equipment Storage (L044) contained 32 oxygen tanks that were not provided with a minimum of 5'-0" separation from the stored materials in this room. NFPA 99 (1999) 8-3.1.11.2(c)(2).


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C. Medical gas cylinders were stored within sprinklered rooms within 5'-0" of combustibles in non-compliance with NFPA 99, 1999, 8-3.1.11.2. Locations observed included:

1. At the 3rd floor CVOR Supply storage room.

2. At the 1st floor Peds ED storage room.

3. At the Lower Level Equipment Storage room at the far north end of the east corridor.


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D. Medical gas tanks were observed being stored, in sprinklered portions of the building, that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). Locations observed include (all Building B):

1. Ninth Floor Clean Utility Room T9021, 3 tanks.

2. Eighth Floor Clean Utility Room T8085, 5 tanks.

3. Fifth Floor Clean Utility Room T5043, 5 tanks.

By direct observation the surveyor finds the facility failed to provide isolation from dissimilar metals for the medical gas piping installation. (NFPA 99, 1999, 4-3.1.2.9)

A. Locations observed but not necessarily limited to Building K Mechanical Penthouse. The installed piping is clamped directly to or resting on painted steel hangers.

Based on random 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:

A. A pipe hanger for an 8"+/- overhead pipe was observed to have the expansion anchor totally dislodged from the structural concrete deck above. Adequate support of the piping system did not appear to be maintained in accordance with standard practice.

B. Stained ceiling tile was observed at the inner corridor near 1-801 which appeared to be from a leaking valve or from condensation due to uninsulated piping.

C. Stained ceiling tile was observed at the exterior door discharge of Stair #1. A potential tripping hazard also existed at the concrete surface outside this door.


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D. 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.

Based on random observation during the survey walk through, it can not be determined how the hyperbaric center meets with NFPA 99, based on the following observations:

A. NFPA 99, 19-2.1.1.2 manufacturers specifications for hyperbaric chambers indicate that the units are placed on casters for mobility in allowing the user to easily reposition or relocate the chamber as required for maintenance. However, it is basically a stationary unit since it must be supplied with oxygen and electrical connections from within the room. If this is the situation on the two chambers, then the room would be required to meet with 19-2.1.1 and a 2 hour room enclosure would be required.

B. The construction Type 2 (000), will not provide a 2 hour rated floor separation.

C. This room contains a 45 minute rated door and the walls are not rated to meet the 2 hour rated requirement.

Based on the observation during the survey walk through, the facility failed to install electrical wiring in accordance with NFPA 101, 2000 Edition, Section 9.1.2 and NFPA 70, 1999 Edition.

Findings include:

A. Building "L", lower level, Environmental office (L051.4), the receptacles were equipped with extension cords and power strips.

B. Building "L", lower level, Purchasing office (L057), the receptacles were equipped with extension cords and additional plug adapters.

C. Building "L", lower level, Dirty dock. An extension cord which was observed that crossed the designated exit path extended the use of an interior wall outlet to provide power to the outside.


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D. Electrical wiring systems were observed not to be in compliance with NFPA 70, National Electric Code. Locations/conditions observed include:

1. It was not clear that electric panel directories readily identified the use of all circuits and the locations served. Panels observed include but are not necessarily limited to the following:

a. Panels located in the corridor serving the 4th floor Cardiology Gym and Locker rooms.

b. Electric panels in 1st floor Electric room 1-318 appeared to have two different panel directories which did not match.

2. The Lower Level Cancer Care Center Mechanical room Electrical room was observed with an open pull-box (where the cover had not been replaced).

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Findings include:

A. Use areas are not separated from exit access corridors or otherwise protected in accordance with the Exceptions granted under 19.3.6.1. Locations and conditions observed include:

1. The 1st floor Emergency Dept. Triage rooms appeared to include patient treatment. the rooms were not separated from the exit access corridor to comply with 19.3.6.1 Exception No. 1, (a).

2. The Emergency Dept. waiting room north vending area was not provided with smoke detection to comply with 19.3.6.1 Exception No. 2, (b).

3. The 2nd floor Maternal/Fetal Medical Clinic waiting area is not provided with smoke detection to comply with 19.3.6.1 Exception No. 2, (b).

4. The "LDRP Unit" reception desk was not provided with smoke detection to comply with 19.3.6.1 Exception No. 1, (c).


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B. Building B First Floor Waiting Room T1077 was observed to lack a smoke detector required by Subpart (b) to Exception 2. of 19.3.6.1.

A. Corridor doors were not provided with positive latching hardware to comply with 19.3.6.3.2. Locations/conditions observed include:

1. The 1st floor corridor door 1-207at the Pacs Reading room suite is equipped with a magnetic locking device which secured the door. The mechanical latch did not engage to comply with 19.3.6.3.2 when the magnetic lock system was released to comply with 7.2.1.6.2. It was not confirmed that the door latch and the magnet lock were tied together to allow the lock to disengage under power loss or fire alarm activation and the door to remain latched.

2. Pairs of corridor doors equipped with power openers and magnetic locking devices were not confirmed to be provided with positive latching hardware upon activation of the fire alarm system and/or loss of power. Under normal operation, the magnetic locking devices appeared to be providing the means by which the doors were being kept closed to comply with the separation of hazardous areas. Locations/conditions observed include but are not necessarily limited to the following:

a. At the Lower Level Housekeeping Storage room across from Care Management offices, it was not clear how latching hardware was provided.

b. At multiple storage room doors along the Lower Level corrdior serving Central Sterile Processing during activation of the fire alarm system, the magnets released, the openers ceased operation, and the mechanical latching hardware was allowed to engage. However, one of the two doors of the pairs did not remain latched at several locations.

c. At the 3rd floor OR Elevator Lobby (T3049) which is designated as a hazardous area and utilized as a storage room, the pair of doors did not have mechanical latching hardware which is required when the magnets are required to release under fire alarm activation/loss of power.

Based on random observation during the survey walk through, not all shafts are constructed or maintained as fire resistive assemblies in accordance with 18.3.1.1.

Findings include:

A. Building C, lower level, Outside EVS staff lounge is a 90 minute rated access door into a shaft which contains the main sanitary stack / tube system / etc. The access door was installed in a cut block opening. The facility could not verify the UL rated design for this installation.


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Based on random observation during the survey walk-through, not all shafts are constructed in accordance with 19.3.1.1.

Findings include:

A. Vertical openings between floors are not protected in accordance with 19.3.1.1 and 8.2.3.2.4. Locations/conditions observed include but are not necessarily limited to the following:

1. 4th Floor Rubbish Chute room (located between the former ICU suites) contained a floor penetration that did not appear to be sealed in accordance with a (UL) tested design.

2. 3rd Floor Men's Toilet room (T3018 adjacent EEG suite?) floor sleeve penetration for heating system piping could not be confirmed to be sealed. This condition of sleeved piping for heating piping existed throughout where visibility of the method of sealing the penetration was not readily observable.

3. 3rd Floor IT closet (T3020 accessed from former Family Waiting) contained unsealed floor penetrations.

4. 3rd Floor Surgery area Electrical room (3123) contained a 4" conduit which appeared not to be sealed.

5. 2nd Floor Telecom room (T2134) contained unsealed floor penetrations.

6. 1st Floor Telecom room (1-210) had what appeared to be a capped/abandoned 10"x10" duct penetration thru the floor above in which duct liner was visible. It was not clear how the 2-hour floor rating was maintained.

7. The dumbwaiter (1267) serving the 1st Floor and Lower Level at the current 1st Floor unoccuppied office area could not be confirmed to maintain the required rating. The shaft enclosure and the shaft access doors could not be confirmed to be minimum 1-hour fire rated assemblies.

8. Lower Level AHU-9 room contained a multi-conduit penetration near the north wall which did not appear to be sealed.

9. Lower Level Mechanical room (0101? containing a fire pump at the west end) was observed with PVC piping penetrations through the floor above which could not be confirmed to be protected in accordance with (UL) tested design assemblies to maintain the 2-hour floor rating.

10. The Lower Level 2-hour rated enclosure between the Morgue and the Biomed Lab was observed with an unrated access panel. The enclosure also contained numerous electrical pull-boxes without covers.

11. The Lower Level Housekeeping Storage room (TB237?) contained copper pipe pentration through the floor which could not be confirmed to be sealed.

12. The Lower Level Electric/Storage room (TB290) contained multiple penetrations through the floor above which could not be confirmed to be sealed.

13. The Lower Level Tool/Equipment Storage room (TB195) contained an electrical pull-box at the ceiling without a cover and several open conduits.

Based on random observation durint the fire alarm testing, it was observed that not all cross corridor fire / smoke doors closed to the latched position.

Findings include:

A. Building "L", 7th floor, 90 minute rated cross corridor doors by room 7006, left leaf did not latch in 2 of 2 attempts.

Based on random observation during the survey walk-through, not all smoke barriers are constructed in accordance with 19.3.7.

Findings include:

A. The 4" conduit sleeve at the cross-corridor doors (S-0465-C) near the 4th floor Vascular Lab 1 was not sealed to maintain the required smoke barrier construction.

Based on random observation during the survey walk-through, not all door openings in smoke barrier walls are constructed or maintained in accordacne with 19.3.7.

Findings include:

A. The corridor door at the 4th floor Vascular Lab 1 is located in a designated smoke barrier wall and was not self-closing to comply with 8.3.4.3. This arrangement does not comply with 19.2.4.3 when the room has its only exit access through the smoke barrier.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 18.3.2.1.

Findings include:

A. "L" Building, 8th floor, Soiled utility (H071), the construction of the back wall is not clear. It appears that a metal stud and gypsum wall board wall was installed in front of a 2 hour rated wall. The 2 hour rated wall only runs about half the length of the soiled utility room. The connection between these two walls was not clear, and it could not be determined that the minimum of 1 hour rating is maintained at the connecting point of these two wall types. The metal stud framing located in front of the 2 hour rated wall is exposed above the ceiling.

B. "L" Building, 3rd floor, Equipment storage (C006), the facilities master plan indicates that the walls are to be 1 hour rated. The wall is stenciled and to be protected to two hour rating. The information provided was conflicting.

C. "L" Building, 2nd floor, Nourishment (B058) the wall is stenciled to maintain 2 hour fire rating. Unsealed sleeves and wall penetrations were observed.


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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

A. Hazardous areas are not separated from adjacent spaces in accordance with 19.3.2.1. Sprinklered hazardous areas are not enclosed including self-closing doors. Locations/conditions observed include:

1. The 3rd floor OR suite containing Clean Utility (3122) has a south door which is not positive latching.

2. The 2nd floor Janitor closet adjacent the LDRP OR Locker rooms contained stored materials. The door was not self-closing.

3. The 1st floor Emergency Dept. Janitor closet (1-162) contained stored materials. The door was not self-closing.

4. The 1st floor Cancer Center "front office" contained rolling files deemed to constitute a degree of hazard greater than that normal to the general occupancy. The door to this space was not self-closing and an unprotected pass-thru window existed to the exit access aisle.

5. The Lower Level door at the Environmental Services Equipment room was not positive latching upon self-closing.


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B. The door to Building F Second Floor File Room T2266 was observed to be held open by an unapproved device (a cardboard box) as prohibited by 19.3.2.1. and 8.2.3.2.3.1(2).

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 38.3.2.1.

Findings include:

A. Soiled Utility Room, door is not self-closing as required for a hazardous area.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. The access door located in Stair #11 at the 3rd floor (T3017) was not confirmed to be installed to maintain the 1 1/2-hour fire rating due to the presence of wood blocking at the frame which was visible from the stair side of the access door.


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B. Fire rated exit passageways were observed at which utilities unrelated to the enclosure (data cables) have been installed as prohibited by 7.1.3.2.1(e). Locations observed include (all First Floor Building B):

1. Exit Passageway for Exit Stair 4.

2. Exit Passageway for Exit Stair 7.

C. Doors to normally unoccupied rooms were observed in fire rated exit enclosures as prohibited by 7.1.3.2.1(d). Locations observed include:

1. Building A Lower Level landing of Exit Stair 3, door to Store Room TB063.

2. Building B First Floor Exit Passageway for Exit Stair 4, door to Store Room T1029.

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2.

Findings include:

A. "L" building, Stairwell doors (all levels, all floors), the hardware installed was not labeled to verify compliance with the 1 1/2 hour rating required by NFPA 80 (1995) 2-8.2.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. The 4th floor Mechanical room above Surgery has a 4" curb at the threshold of the west stair door and the adjacent elevator machine room door in non-compliance with 7.2.1.3.

B. The 3rd floor access to the northeast Stair requires passage through a corridor area constructed as a room which is being used for miscellaneous equipment and cover gowning apparrel. The minimum 8'-0" clear width is not maintained to the stair door and the door between the corridor and the corridor being utilized as a room is not a minimum 41.5" clear width.

C. The 2nd floor Medical Library west exit to the stair has a step at the door in non-compliance with 7.2.1.3.

D. The 1st floor Emergency Dept. Lobby entrance has a revolving door marked as an exit. Conditions observed include:

1. The revolving door does not have an adjacent complying swinging door within a minimum 20' to comply with 7.2.1.10.1(e) Exception No. 2.

2. It was not confirmed that the revolving door complies with 7.2.1.10.2 regarding this door being utilized as a component of the required means of egress.

E. The 1st floor Cancer Center Supply closet is equipped with both a lever handle latch-set and a combination lock/knob-set. The combination lock-set is mounted above the original lever-handle latch-set. The original lever-handle latch-set has been rendered non-functional but its presence on the door can confuse egress since the combination lock-set is at non-standard height and is actually the functional hardware. The appearance of more than one operation to open the door is present and non-compliant with 7.2.1.5.4.

F. Dead bolt locks used in combination with door latch-sets can require more than one operation to open the door in non-compliance with 7.2.1.5.4. Locations observed include but may not necessarily be limited to the following:

1. Three office rooms at the 2nd floor Medical Library.

2. 1st floor Ultrasound rooms 1-254 & 1-253.

3. 1st floor CT Scan rooms 1-314 & 1-315.

G. Doors are equipped with magnetic locking devices which do not comply with all the requirements of 7.2.1.6.2, Access Controlled Egress Doors with particular reference to 7.2.1.6.2(c) regarding the manual release. Locations observed include but are not necessarily limited to the following:

1. 2nd floor Neonatal Nursery west corridor door lacked manual release.

2. 2nd floor east exit from the Medical Library lacked manual release.

3. 1st floor Nuclear Med suite south corridor door required the use of the manual release. The sensor required by 7.2.1.6.2(a) appeared not to be operational.

4. Lower Level door at Housekeeping Storage across from Care Management office lacked manual release.


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H. Most doors to Exit Stairs within Building B (including Exit Stairs 4, 5, 6, and 7) were observed to be equipped with locking devices that are capable of preventing re-entry to the building in a manner prohibited by 7.2.1.5.2.

I. The Building B Sub-Basement was observed was observed to lack at least 1 exit stair which discharges directly to the exterior of the building as required by 7.7.2.

J. Cross-corridor doors identified with signage as exit paths were observed to be locked to prevent egress as prohibited by 7.2.1.5.1. Locations observed include (all Second Floor):

1. Pair of doors at east end of Building B Corridor T2140 (doors to Adult Psychiatric Unit)

2. Pair of doors at north end of Building F Corridor T2177 (doors to Pediatric Psychiatric Unit).

K. Two delayed egress locks were observed, in the egress path from Building B Fifth Floor Corridor T5015 to Exit Stair 6, as prohibited by Exception 2. to 19.2.2.2.4.

Based on random observation during the survey walk through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 18.2.10.1 and 7.10.

Findings include:

A. "L", 1st floor, elevator lobby of Administrative suite, did not contain an exit sign identifying which door is the egress path.


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Based on random observation during the survey walk through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1 and 7.10.

Findings include:

A. Exit and directional exit signage was not provided to clearly identify the required means of egress to comply with 19.2.5.9 and 19.2.10. Locations/conditions observed include:

1. Exit signage is blocked by other signage in the 3rd floor corridor serving the "Holter Pulmonary" suite.

2. Exit signage to the north to provide two separate paths of travel is not provided in the 3rd floor corridor serving the Endoscopy rooms.

3. Exit signage is not provided on the south side of the 2nd floor cross-corrdior doors near the "rear" door to the Neonatal Special Care Nursery suite to identify two separate exit travel paths.

4. An exit sign in the Lower Level mechanical fan room serving the Cancer Care Center was not illuminated.

5. Directional exit signage was observed on the east side of the cross-corridor doors near Elevators #11 & #12 where non-directional signage is appropriate.

6. Exit signage to identify two separate paths of travel to and exit was not provided within the 1st floor Emergency Dept. suite containing "Nurse Station T1440".

7. Exit signage to identify two separate paths of travel within the 1st floor corridor serving the Pacs Reading rooms was not provided.

8. Exit signage to identify two separate paths of travel within the 1st floor corridor serving the Ultrasound rooms #3 & #4 was not provided.

9. Exit signage to identify two separate paths of travel within 1st floor Corridor 1401 was not provided.

10. Exit signage to identify separate paths of travel in the corridor sections east of the Emergency Dept. was not provided (both sides of two sets of double egress cross-corrdior doors).

11. Exit signage at the 1st floor Cancer Care Center north door is obstructed by other signage.

12. Exit signage to identify two separate paths of travel within the 1st floor corridor serving the CT Scan rooms was not provided.

13. Directional exit signage is provided at the 1st floor corridor directing occupant through the MRI area. It is not clear why exiting is directed through this area when other paths appear to be provided. This path requires the traversing of an unenclosed stair which accesses the MRI are which is a half-level floor level change below the remainder of the 1st floor. The MRI corridor is obstructed by a belt stretched across the corridor path to limit normal traffic from gaining close access to the MRI rooms.

14. Exit signage to identify two separate paths of travel within the Lower Level corridor serving the Central Supply room and other Storage rooms was not provided and was obstructed by other signage.

15. Exit signage at the west door within the Lower Level Mechanical room containing the fire pump which accesses the corridor serving the LDRP OR elevators is mounted flat on the wall where a sign perpendicular to the wall is required to allow it to be visible remote from the door.

Based on random observation during the survey walk through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 39.2.10.1 and 7.10.

Findings include:

A. Exit corridor is approximately 214' in length. The corridor only contains two exit signs, one at each end of the corridor. The distance between these exit signs exceeds the 100' maximum allowed 7.10.1.4.

B
ased on direct observation during the survey walk through not all smoke detectors were installed in accordance with NFPA 72.

Findings include:

A. "L" building, 1st floor, Coffee Shop, the smoke detectors are located in the airflow and may prevent operation of the detectors. NFPA 72, 2-3.5.1.

B. "L" building, Lower Level, during the fire alarm test the cross corridor doors by the lab did not release. The magnetic hold open devices were not equipped with a smoke detector on either side of the doors to comply with NFPA 72, 2-10.6.

Based on random observation during the survey walk through, not al portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13, 1999.

Findings include:

A. Rooms and spaces were observed at which sprinkler layout was observed to not provide complete coverage as specified by NFPA 13, 1999. Locations observed include:

1. Lobby, the sprinklers are locate under the soffits at the perimeter of the room. The center of the room contains a raised ceiling and a large shelving unit which is not provided with any sprinkler coverage.

Based on random observation during the survey walk through, not al portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13, 1999.

Findings include:

A. Rooms and spaces were observed at which ceiling tile were observed to be missing or contained penetrations, which compromises sprinkler coverage as prohibited by NFPA 13, 1999, 5-6.4.1.1 and 5-7.4.1.1. Locations observed include:

1. "L" building, 1st floor, AV control room (A017) several ceiling tiles were missing, or not installed in the ceiling track.

2. "C" building, Lower Level, several damaged ceiling tiles were observed in the kitchen. They include broken tiles and damaged tiles which may compromise the sprinkler system.

B. Rooms and spaces were observed at which sprinkler heads were observed collecting a visible accumulation of dust and dirt. NFPA 25, 1995, 2-2.1.1 Locations observed include:

1. "C" building, Lower Level, Kitchen, at the food service line.


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C. Installed sprinkler systems are not in compliance with NFPA 13. Locations and conditions observed include:

1. Sprinkler piping observed in the 4th floor Vascular Lab appeared to have an unsupported length greater than that allowed under NFPA 13, 1999, 6-2.3.

2. The sprinkler head located in the 3rd floor OR Environmental Services closet appeared tobe obstructed by the light fixture.

3. The small L-shaped closet within the 3rd floor CVOR Supply room did not have a ceiling which left the space open to the ceiling cavity of the adjacent Supply room. The size of the ceiling cavity was not determined at the time of the survey and it was not confirmed if other sprinklers existed above the lay-in ceiling of the adjacent Supply room.

4. The shelving installed in the 2nd floor Storage room (T2208) obstructed the sprinkler head.

5. The sprinkler head located in the 2nd floor (Data) Storage room (T2135) was obstructed by shelving/materials less than 18" clearance below the head in non-compliance with NFPA 13, 1999, 5-5.5.2.1.

6. The sprinkler head located near the northwest corner of the Lower Level Film Storage room (TB174) was obstructed by shelving/material less than 18" clearance below the head in non-compliance with NFPA 13, 1999, 5-5.5.2.1.

7. The Lower Level room(s) housing Electric Substation No. 6 are not fully sprinklered. The room is indicated to have a 2-hour separation but not all ducts appeared to be provided with fire dampers to comply with NFPA 13, 1999, 5-13.11 Exception for electrical rooms.

8. The sprinkler heads located in the Lower Level Respiratory Care Educator's Office were less than 6'-0" apart in non-compliance with NFPA 13, 1999, 5-6.3.4. It was noted that an accordian door whci previously existed had been removed.

9. A sprinkler head located in the Lower Level Elevtric/Storage room (TB290) was installed in the pendant position while others in the room were installed in the up-right position. Compliance with NFPA 13, 1999, 5-6.4.1.


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D. Vacated Laboratory Room T1143 was observed to lack a ceiling system, and the interstitial spaces above the ceilings in all spaces directly to the east of that room were observed to be open to Room T1143. Sprinkler coverage for that portion of the building was thus observed to be compromised as prohibited by NFPA 13 1999 5-6.4.1.1.


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By direct observation and staff interview the surveyor finds the facility failed to provide:

A Fire suppression for the following areas:

1. Will County Radio Room

2. Joliet City Radio Room

3. D Building emergency switchgear room

4. Elevator 13 machine room

5. 5th Floor Building B service elevator machine room

6. Electrical room by Medical Word Processing

B. Electronic supervision of all fire sprinkler water supply valves. Valve located in the Lower Level B Building, as observed through the glass ceiling inspection panels, are chained and padlocked but not electronically supervised by the fire alarm system.

Based on random observation during the survey walk through, not al portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13, 1999.
Findings include:

A Rooms and spaces were observed at which sprinkler escutcheon rings were observed to be missing as prohibited by NFPA 13, 1999. Locations observed include:

1. Biohazard Room.

B. Rooms and spaces were observed at which ceiling tile were observed to be missing or contained penetrations, which compromises sprinkler coverage as prohibited by NFPA 13, 1999, 5-6.4.1.1 and 5-7.4.1.1. Locations observed include:

1. Storage room behind the nursing desk, the ceiling tiles were over cut creating a large gap around the wire bundle penetration.

Based on random observation during the survey walk through not all portable fire extinguishers in the facility are installed and maintained in accordance with 18.3.5.6, 9.7.4.1 and NFPA 10.

Findings include:

A. "L" building, all floors, the fire extinguishers are installed at the ends of the corridor in a seating area across from the exit stairs. The cabinets are not readily accessible or immediately available in the event of a fire as required by NFPA 10, 1-6 due to the furniture placement in these areas.

Based on random observation during the survey walk-through and document review, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A.

Findings include:

A. A series of shafts housing toilet exhaust ducts were observed, throughout Building B, which do not carry a minimum 2 hour fire resistance rating required by NFPA 90A 1999 3-3.4.1. Surveyor 14290 notes that, according to the provider's Life Safety Drawings, there appear to be 18 such shafts and that they appear to communicate with the Ninth through Second Floors.

B. The door to Mechanical Room T4178, which constitutes a ventilation shaft at least 4 stories in height, was observed to lack a minimum 1-1/2 hour fire rating required by 8.2.3.2.3.1(1) and NFPA 90A 1999 3-3.4.1.

C. The door to Mechanical Room T2174, which constitutes a ventilation shaft at least 4 stories in height, was observed to not be self-closing as required by 8.2.3.2.3.1(1) and NFPA 90A 1999 3-3.4.1.



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By direct observation the facility failed to provide:

A. Fire dampers for the floor duct penetrations of supply and return/exhaust ventilation systems originating in the 5th floor C Building mechanical room. (NFPA 90A, 1999, 3-3.2)

B. Fire dampers for the duct penetrations through the north wall of the duct shaft (T2174) 2nd floor B Building. (NFPA 90A, 1999, 3-3-4.4)

Based on document review and staff interview, not all portions of the facility's commercial cooking equipment is installed and maintained in accordance with NFPA 96.

Findings include:

A. During the document review process it could not be determined whether the Kitchen hood exhaust ductwork is periodically inspcted for cleaning, as required by NFPA 96 1998 8-3.1., because no records of such cleaning were available. During an interview held in the Facilities Conference Room on the afternoon of may 25, 2010, the provider's Director of Safety and Security confirmed this observation.

Based on random observation during the survey walk through, not all linen or refuse chutes are constructed and maintained as fire resistive assemblies.

Findings include:

A. "L" building, 7th floor, (G060), the waste and linen chutes that are 4 or more stories in height were observed that are not constructed as 2 hour fire rated assemblies as required by 8.2.5.4.(1) and NFPA 82 (1996) 3-2.3 because the latching hardware was not functioning and/or missing.


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B. Lower Level Linen Chute discharge room (TB125? adjacent Central Supply) contained a duct penetration in the corridor wall which could not be confirmed to contain a fire damper.

Based on random observation during the survey walk through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 18.2.3.3 and 7.1.10.2.1. Findings include:

A. "L" building, 8th Floor, ICU contains nursing stations located in niches between patient rooms. The chairs located at each nursing station were found to be unoccupied, and left in the exit path.

B. "L" building, 7th Floor, ICU contains nursing stations located in niches between patient rooms. The chairs located at each nursing station were found to be unoccupied, and left in the exit path.

C. "L" building, Lower Level, Exit path to the dirty dock contains large containers of carboard trash.



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Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. Means of egress corridors are not maintained free of obstructions to comply with 7.1.10. Locations/conditions observed include:

1. The 3rd floor Surgery Dept. is a combination of suites and exit access corridors. The exit access corridors are utilized for storage of equipment/stretchers/carts used in the ORs. The full width of the corridors are not available for full instant use. Although alcove spaces are provided, the amount of equipment stationed open to the corridors exceeds the available space of the alcoves.


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B. Chairs or stools were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. Building B:

a. Fourth Floor:

1. Corridor T4243.

2. Corridor T4275

3. Corridor T4300.

b. Third Floor:

1. Corridor T3143.

2. Corridor T3153.

3. Corridor T3125.

2. Building F Second Floor Corridor T2177.

Based on random observation during the survey walk through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. "L" building, 7th floor, Equipment Storage (G075), contained eight oxygen tanks that were not provided with a minimum of 5'-0"separation from the stored materials in this room based on NFPA 99 (1999) 8-3.1.11.2(c)(2).

B. "L" building, Lower Level, Medical Equipment Storage (L044) contained 32 oxygen tanks that were not provided with a minimum of 5'-0" separation from the stored materials in this room. NFPA 99 (1999) 8-3.1.11.2(c)(2).


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C. Medical gas cylinders were stored within sprinklered rooms within 5'-0" of combustibles in non-compliance with NFPA 99, 1999, 8-3.1.11.2. Locations observed included:

1. At the 3rd floor CVOR Supply storage room.

2. At the 1st floor Peds ED storage room.

3. At the Lower Level Equipment Storage room at the far north end of the east corridor.


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D. Medical gas tanks were observed being stored, in sprinklered portions of the building, that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). Locations observed include (all Building B):

1. Ninth Floor Clean Utility Room T9021, 3 tanks.

2. Eighth Floor Clean Utility Room T8085, 5 tanks.

3. Fifth Floor Clean Utility Room T5043, 5 tanks.

By direct observation the surveyor finds the facility failed to provide isolation from dissimilar metals for the medical gas piping installation. (NFPA 99, 1999, 4-3.1.2.9)

A. Locations observed but not necessarily limited to Building K Mechanical Penthouse. The installed piping is clamped directly to or resting on painted steel hangers.

Based on random 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:

A. A pipe hanger for an 8"+/- overhead pipe was observed to have the expansion anchor totally dislodged from the structural concrete deck above. Adequate support of the piping system did not appear to be maintained in accordance with standard practice.

B. Stained ceiling tile was observed at the inner corridor near 1-801 which appeared to be from a leaking valve or from condensation due to uninsulated piping.

C. Stained ceiling tile was observed at the exterior door discharge of Stair #1. A potential tripping hazard also existed at the concrete surface outside this door.


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D. 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.

Based on random observation during the survey walk through, it can not be determined how the hyperbaric center meets with NFPA 99, based on the following observations:

A. NFPA 99, 19-2.1.1.2 manufacturers specifications for hyperbaric chambers indicate that the units are placed on casters for mobility in allowing the user to easily reposition or relocate the chamber as required for maintenance. However, it is basically a stationary unit since it must be supplied with oxygen and electrical connections from within the room. If this is the situation on the two chambers, then the room would be required to meet with 19-2.1.1 and a 2 hour room enclosure would be required.

B. The construction Type 2 (000), will not provide a 2 hour rated floor separation.

C. This room contains a 45 minute rated door and the walls are not rated to meet the 2 hour rated requirement.

Based on the observation during the survey walk through, the facility failed to install electrical wiring in accordance with NFPA 101, 2000 Edition, Section 9.1.2 and NFPA 70, 1999 Edition.

Findings include:

A. Building "L", lower level, Environmental office (L051.4), the receptacles were equipped with extension cords and power strips.

B. Building "L", lower level, Purchasing office (L057), the receptacles were equipped with extension cords and additional plug adapters.

C. Building "L", lower level, Dirty dock. An extension cord which was observed that crossed the designated exit path extended the use of an interior wall outlet to provide power to the outside.


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D. Electrical wiring systems were observed not to be in compliance with NFPA 70, National Electric Code. Locations/conditions observed include:

1. It was not clear that electric panel directories readily identified the use of all circuits and the locations served. Panels observed include but are not necessarily limited to the following:

a. Panels located in the corridor serving the 4th floor Cardiology Gym and Locker rooms.

b. Electric panels in 1st floor Electric room 1-318 appeared to have two different panel directories which did not match.

2. The Lower Level Cancer Care Center Mechanical room Electrical room was observed with an open pull-box (where the cover had not been replaced).