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A) Based on random observation during the survey walk-through, the surveyor finds that not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. Portions of steel beams were observed with missing fire proofing. Locations observed include:

1) 4th Floor NICU Room 4335

2) Basement Level

a) Stair # 7 has an access panel in the stair
enclosure, one half level up from the
Basement. There is a steel beam above
the space behind this access panel that is
missing fire proofing on a portion of the
beam.

b) C906 - Mechanical Space: fire proofing
is missing from the bottom flange of a
steel beam in the southeast corner of this
space.

c) There is a pair of fire doors next to
Room C288. Fire proofing is missing from a
beam above the ceiling, west of the
doors.



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Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

B. 5th floor, above the cross corridor doors by "Tel Closet" 5102W, portions of the steel structure were observed not covered by fire proofing material in accordance with the designated building construction type.

C. 1st floor, ER ambulance canopy contains metal columns that support this roofing system and are not enclosed or provided with fire proofing material.



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D. Portions of the steel structure were observed that are not covered by fire proofing materials in accordance with the designated building construction type. Locations observed include:

1. Eighth Floor:
a. Data Closet 8106W.

b. Immediately outside Exit Stair 8-S4.

2. Fourth Floor Elevator Machine Room 4210A.

A) From random observation, the surveyor finds that spaces open to corridors do not comply with the exceptions under 19.3.6.1:

1) The Basement Level C100 Rehabilitation Services (Inpatient/Outpatient) has patient treatment bays that are open to the adjacent corridors or aisles. This condition does not comply with 19.3.6.1. Based upon this, the surveyor finds that this space is very likely intended to be a health care suite (treatment suite). No information is provided that identifies this space as a suite (see K048). The size and boundaries of the suite are not clearly identified. How two remote paths of egress are provided in accordance with 19.2.5.3 are not identified (see also K038 and K042).



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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:

B. Staff work areas which are open to the corridors were observed which are not provided with smoke detectors required by Exception 1. [subpart(c)] to 19.3.6.1. (also refer to K-048). Locations observed include (all Second Floor):

1. Radiology Unit Work Areas as part of Corridors 2286, 2339, and 2343.

2. Imaging Unit Work Areas as part of Corridor 2477.

3. Cardiac Cath Unit Work Areas as part of Corridor 2199.

4. Office Unit Work Areas as part of Corridor 2201.

5. Treatment Unit Work Areas as part of Corridor 2200.

C. Treatment rooms were observed that are open to corridors as prohibited by 19.3.6.1. (also refer to K-048). Locations observed include (all Second Floor):

1. Several Radiology Rooms served by Corridors 2286, 2339, and 2343.

2. Prep/Recovery Room 2125.

Based on random observations during the survey walk-through, not all doors in the exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. 7th floor, 7W0T Transplant ICU (can not be a suite) and contains doors in the exit access corridor that were observed not to be equipped with positive latching hardware as required by 19.3.6.3.2.

1. Room 735W

2. Room 736W

3. Room 737W

4. Room 738W


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B. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. Locations observed include:

1. Sixth Floor:

a) Patient Isolation Room 677WA.

b) Patient Isolation Room 677WB.

2. Fourth Floor Sub-Sterile Room 4272, 2 doors to adjacent Operating Rooms (also refer to K-048).

3. Second Floor Radiology Suite which includes Corridor 2286, several Treatment Rooms (also refer to K-048).

C. The door to Fourth Floor Sonogram Room 4201 was observed to be obstructed in manner that will prevent the door from closing, as required by 19.3.6.3.2., by a curtain and by items hanging from the door latchset.

D. A dutch door was observed, at Second Floor Procedure Room 2313, which does not comply with 19.3.6.3.6. because:

1. The upper leaf was observed to not positively latch to the lower leaf (slide bolt only).

2. The assembly was observed to not include a bevel, rabbet, or astragal at the meeting edge.

A) Based upon random observation ,the surveyor finds that vertical opening and protection of vertical openings are not installed and maintained in accordance with Section 8.2.3.2 and 8.2.5:

1) 9th Floor - Stair # 4: The 1 1/2 hour access panel in the stair wall is not self closing (spring for access panel was missing).



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

Findings include:

B. Openings were observed in ventilation or other shafts that are not sealed against the passage of fire as required by 8.2.5.4. Locations and types of openings observed include (all Eighth Floor):

1. Break Room 870E, opening in designated 2 hour fire rated shaft wall covered with single layer of drywall.

2. Lounge 860E, unsealed pipe penetration in designated 2 hour fire rated shaft wall covered with single layer of drywall.

C. The fire rated access panel to the Elevator Shaft from Fourth Floor Elevator Machine Room 4210A was observed to not be self-closing, as required by 8.2.3.2.3.1(1), because:

1. The spring was observed to have been removed.

2. A pair of wires extends through the access panel to the Elevator Control Panel, thus preventing the access panel from closing.

Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintain the fire resistive assemblies in accordance with 39.3.1.1.
Findings include:

A. Random (observed at 8th and 6th), the pipe shafts located in the elevator and stairs are not sealed. The shaft enclosure contained a rated door but it was installed directly to the open CMU block. The installation observed is not a UL approved method.

1. The rated door to the shaft was observed to not be a self closing and latching door, since the "spring" has been removed.

Based on random observation during the survey walk-through, not all doors to exit enclosures are held open by devices arranged to automatically close the doors as required by 19.2.2.2.6.

Findings include:

A. The Sixth Floor door to Exit Stair 1 was observed to be held open by a chair as prohibited by 19.2.2.2.6. and 7.2.1.8.2.

A) From random observation, the surveyors find that hazardous areas are not enclosed in accordance with 19.3.2.1, and/or 8.4.1.1 and hazardous areas are not separated from other use areas.

1) The Basement Level (Concourse) has a 12' wide, Main Corridor that extends east and west the length of the building. The Basement Level lacks a separate holding area for soiled linen, soiled waste and bio-hazard waste. The 12' wide Basement Corridor is used to stage and hold equipment, supplies, and furniture, along with soiled linen carts, waste carts and bio-hazard waste. The west end of the corridor by the end of the day is filled with soiled materials carts to the point that access to the west stair (Stair # 2) becomes blocked.

a) The 12' wide corridor is a required
means of egress for multiple office and
service areas at this level (but not for
health care). The means of egress for
such areas are prohibited from exit
through this area of higher hazard as
prohiited by 39.3.2.1. and 8.4.1.1.

2) Basement Level:

a) Chemical Storage C444: the door to this
room is not self closing

b) The Dumbwaiter Machine Room (624)
has a hole in the enclosure wall at a
junction box.



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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:

B. Hazardous areas covered by a sprinkler system were observed at which doors are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

1. Eighth Floor Patient Belongings Room 841E.

2. Fourth Floor Clean Storage Room 4261.

3. Second Floor File Storage Room 2504.

Based on random observation during the survey walk-through and document review, not all laboratories employing quantities of flammable, combustible, or hazardous materials are protected in accordance with NFPA 99.

Findings include:

A. 3rd floor Lab:

1. The Lab is not indicated on the master life safety plans as being enclosed by 1 hour rated construction as specified by NFPA 99, 10.3.1.1.
2. Room 3134A, contains storage of wax blocks that are not being stored in a rated enclosure and/or room.

A) Exit enclosures including exit stair are identified on documents as having two hour fire rated enclosures. These enclosures are compromised and do not comply with 7.1.3.2, 7.1.3.2.1 e) and/or 7.2.2.5.3.

1) Stair # 4 has an IS Shaft immediately next to the stair enclosure. The common wall between the two vertical openings is a 4" concrete block wall with a space and then another 4" concrete block wall.

a) The stair enclose at the Basement Level
has a fire rated access panel in the lower
wall. The hose cabinet above the access
panel penetrates one layer of 4" block
and is not fire rated. There is a hole in
the 4" block of the IS Shaft behind the
access panel. It could thus not be determined
that a complete 2 hour fire barrier exists
between the IS Shaft and the Exit Stair.

2) Stair # 7 has an access panel in the stair enclosure, one half level up from the Basement. This access panel is positive latching and self closing but is not a fire rated access panel.

3) Stair # 2 - Basement Level: There is a hole in the south soffit of the stair, under the landing. Also, there a black cable strapped to an electrical conduit that runs through the stair enclosure. The cable and possible the conduit are not permitted under 7.1.3.2.1 e).

4) Stair # 1 - Basement Level: A cart was left in this stair, under the landing.



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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:

B. 5th floor, Stair #4 (5-S4) the shaft adjacent to the stair well contains sprinkler piping that penetrates the stair enclosure and is not sealed on the shaft side to maintain the 2 hour rating.

C. Floor #3, Stair #6 the door to the stairwell did not close to the latched position without assistance.



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D. A portion of the concrete block above the door at Eighth Floor Exit Stair 8-S4 was observed to be missing, thus the wall is not sealed against the passage of fire as required by 8.2.5.4. and 8.2.3.2.4.2.

E. At the Concourse Level of Exit Stair 1, 3 duct penetrations were observed which lack fire dampers required by 8.2.5.4. and NFPA 90A 3-3.1.1.

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

Findings include:

A. The pair of doors between First Floor Corridor 1012 (which is shown on provided drawings as an exit passageway) and Waiting Room 1011 was observed to not carry a minimum fire resistance rating of 1-1/2 hours as required by 8.2.3.2.3.1.(1) (also refer to K-048).

B. First Floor Corridor 1012, which is shown on the provided drawings as an exit passageway for Exit Stair S-1, was observed to:

1. House 2 Elevators as prohibited by 7.1.3.2.3.

2. Contain an opening from Janitor Closet 1012A, which constitutes a not normally occupied room, as prohibited by 7.1.3.2.1(d).

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. (modfiied 07/02/10): The Exit Stair Enclosure was observed to house, at all building levels, the Elevator Lobby as prohibited by 9.4.7 This condition was observed at ;
1. The South Elevator/Stair.

2. The North Elevator/Stair.

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. 7th floor, Stair #3 (7-S3) a bed table tray was observed being stored in the exit stairs as prohibited by 7.2.2.5.3.


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B. Exit stairs were observed at which re-entry to the building is not permitted as required by 7.2.1.5.2., because re-entry can only be accomplished with the use of a key. Further, no signage was observed within the exit stairs which clarify to building occupants that re-entry is not permitted. This condition was observed at all building stories at the exit stairs listed below:

1. Exit Stair 1.

2. Exit Stair 2.

3. Exit Stair 3.

4. Exit Stair 5.

5. Exit Stair 6.

6. Exit Stair 7.

C. Exit stairs were observed that are not provided with signage within the enclosure that identifies the story, the top and bottom terminus, and the stair enclosure identification which is visible without entering the Exit Stair and closing the door. Locations observed include:

1. Exit Stair 1.

2. Exit Stair 2.

3. Exit Stair 3.

4. Exit Stair 4.

5. Exit Stair 5.

6. Exit Stair 6.

7. Exit Stair 7.

D. Exit stairs were observed at which utilities had been recently installed that are not related to the conditioning or operation of the stair, as prohibited by 7.1.3.2.1.e. Locations and utilities observed include (all Exit Stair 2):

1. Second Floor Landing, 3 conduits an 1 device served by a coaxial cable.

2. First Floor Landing, 1 conduit and junction box.

A) Based upon random observation, the surveyors find that exit paths are not provided and maintained as a protected path to a public way.

1) The Basement Level C100 Rehabilitation Services (Inpatient/Outpatient) appears to be a health care suite (patient treatment) (see K017 and K048). It has been evaluated as a suite under this tag. This suite currently has three identified means of egress out of it. One is to a corridor door that serve as the entrance to this unit. A 2nd path is directed to the South Stair (Stair # 5). The 3rd path from this unit is directed east into and through an area that was formerly a hydrotherapy area and part of the Rehab Unit.

a) A portion of the Hydrotherapy area has been turned into a workshop and storage area. This constitutes a change of use and the use is a hazardous area. This former Hydrotherapy area is not separated from the Rehab Department by one hour fire rated barriers in accordance with 18.3.2.1. The two pairs of doors that connect Hydrotherapy to the Rehab Department lack 3/4 hour fire rated doors with self closing and positive latching hardware (18.3.2.1). And the exit path is directed into and through this hazardous area (does not comply with 7.5.2.1) and is then directed through the Dietary Department (does not comply with 7.5.2.1).

b) There is a foyer between the former Hydrotherapy area and Dietary. The identified exit path from this foyer is north, into Dietary from Hydrotherapy and the Rehab Unit. This foyer has only one way out, to the north. Re-entry back into Hydrotherapy can be obstructed by a manual slide bolt on the door in that direction.

c) The "walk-in cooler/walk-in freezer corridor" north of the above foyer is a long, corridor like space with a door and exit sign to the north. As an exit access corridor, this space lacks two remote paths of egress and constitutes a 56' dead end corridor to the south. This space cannot use the hazardous area to the southwest (former Hydrotherapy) as a means of egress (7.5.2.1) and it cannot use a suite (Rehab) as a means of egress.

The pair of doors to the south lack signage indicating "Not an Exit" and the pair of doors to the north lack signage on the north side of the doors (inside the Kitchen area) indicating "Not an Exit".

2) Basement Level Dietary Department: The Kitchen has multiple walk-in coolers and freezers. Some of them have two doors. Many of the doors were observed to have padlocks. One means of egress from each walk-in unit is not maintained (without a padlock) in accordance with 7.2.1.5.

3) There is a north/south corridor-like-space (C292) that is currently being used for wheelchair storage. This space has a fire door that leads into Building 924. The door is locked. The door lacks a sign indicating that it is not an exit leading into building 924 (7.10.8.1)



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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:

B. Stair #2, 1st floor from cafeteria the stair discharges to the exterior at this level. The stairs continue beyond the level of exit discharge and are not equipped with in interrupter gate as required by 7.7.3.


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C. Dead-end corridors of excessive length were observed as prohibited by 19.2.5.10. (also refer to K-048). Locations observed include (all Second Floor):

1. Imaging unit Corridor 2477.

2. Cardiac Cath Unit Corridor 2199.

D. Second Floor Corridor 2314 was observed to lack 2 remote exits. required by 19.2.5.9., because no exit sign exit sign was observed at the south end of the Corridor (also refer to K-048).

E. The padlock for the accordion door serving Eighth Floor Storage Alcove 886EB was observed to be keyed differently than all other keys in the Psychiatric Unit; thus all staff does not carry the key to this space as required by Exception 1. to 19.2.2.2.4.

A) Based on observation, the surveyors find that the Basement Level C100 Rehabilitation Services appears to be a patient treatment area suite (see K038 and K048). It has three identified exit paths. The exit path to the east is not permitted and cannot be counted as an exit path (see K038). One exit path leads to an exit stair. This path to the stair can be counted as an exit path only if the primary exit path from the most remote point in the suite to a corridor door is less than 100' (19.2.5.8). The primary exit path does not comply with this section.



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Based on random observation during the walk-through, not all designated suites are provided with exits in accordance with 19.2.5.

Findings include:

B. 3rd floor, the designated OR Suite exceeds 10,000 square feet as prohibited by 19.2.5.7.

C. 1st floor, the designated ER suite exceeds 10,000 square feet in size as prohiibted by 19.2.5.7..

A) Based upon random observation throughout the Hospital, the surveyors find that Horizontal Exits and/or designated two and three hour fire barriers do not comply with 19.1.2.4, 19.2.2.5, 7.2.4, and/or 8.2.3 (where applicable):

1) Horizontal Exits are not clearly identified on the Life Safety Master Plans (see K048)

2) Basement Level C600: The pair of fire doors to this space has one leaf that does not close to latch.

3) Basement Level C900: The pair of fire doors to this space have an active/inactive leaf arrangement. The automatic flush bolts on the inactive leaf were disabled. The inactive leaf lacks positive latching hardware.

B) 10th Floor - Large Elevator Machine Room: The fire door opposite AHU S-1 does not close to latch. Air pressure keeps the door from closing automatically.



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Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

B. 5th floor, during the fire alarm testing the cross corridor doors to PEDs ICU did not close and latch because they were binding on the flooring material.


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C. The pair of doors in the designated 3 hour fire rated wall at the east end of Corridor 5053E were observed to not close upon activation of the building fire alarm system, as required by 7.2.4.3.8. and 8.2.3.2.3.1(1), because the doors are held open by the flooring material.

D. A pipe was observed to be embedded in the designated 3 hour fire wall at Electrical Closet 803W; thus the wall is not sealed against the passage of fire at that location as required by 8.2.3.2.4.2.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. Three pipe penetrations, through the designated 3 hour fire rated wall in Mechanical Equipment Room C405 (at the Steam Tunnel), were observed to not be sealed against the passage of fire as required by 8.2.3.2.4.2.

A) Based upon random observation the surveyor finds that illuminated exit signs or directional signs are not always provided, where required by 19.2.10.1:

1) The Basement Level (Concourse) has a 12' wide Main Corridor extends east and west the length of the building. There is a fire shutter that divides this corridor at the middle of the building, into two separate fire compartments. Western comparments lacks exit signs that direct the means of egress to an exit. Two pairs of doors near the fire shutter, on the west side of the shutter, lack illuminated exit signs directing the path around the fire shutter back to an exit path to the east (through C051 and C052).

2) Basement Corridor C051 and C052 is a required exit access corridor for the C100 Rehabilitation Services Unit and for the Unit to the west that contains the Islet Lab. The surveyor notes that exit access corridors, suites and horizontal exits are not clearly identified on plan provided by the facility (see K048). The surveyor finds that Corridor C051/C052 lacks an identified send means of egress out of the corridor in accordance with 19.2.5.8. The Vestibule C291 that is north of C051 has two pairs of doors that swing to the south and not in the direction of exit travel (opposite swinging doors required because of item 1 above and item 2).

a) The 1st set of doors (south pair of doors for Vestibule C291) are not identified as fire doors that are part of an existing horizontal exit. An exit sign directing the exit path north is not provided. One of two door leafs on this pair of doors does not swing in the direction of exit travel.

b) The north pair of doors in Vestibule C291 are identified as three hour fire doors. An exit sign directing the exit path north is not provided. They are not identified as an existing horizontal exit (but may be required as such). If this pair of fire doors is not an existing horizontal, one of two door leafs on this pair of doors does not swing in the direction of exit travel.

Based on random observation during the survey walk-through, not all exits are identified in accordance with 7.10.

Findings include:

A. At the Basement, two exit signs are not illuminated in the path to entrance B1CA as required by 7.10..

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. An exit sign was observed, above a door from Second Floor Suite 2C which can be secured against egress, which does not direct occupants toward an exit as required by 7.10.1.1.

B. Exit signs were observed that are not continuously illuminated as required by 7.10.5.2. Locations observed include:

1. Corridor 1016, exit sign at north end.

2. Corridor 1014, exit sign at east end.

A) The surveyors reviewed the Hospital written fire plan. Their plan indicates that they follow the R A C E acronym and the surveyors observed that RACE instructions are posted throughout the Hospital.

1) The Hospital indicates that the current fire alarm system annunciates throughout the entire facility and then staff response throughout the entire facility is expected to follow the RACE acronym. However: This is not clearly indicated in their written fire plan

a) The written plan does not clearly indicate that staff is expected to follow the RACE acronym, throughout the hospitals during fire drills.

b) Portions of the written fire plan have instruction that conflict with the RACE acronym. Item "D," subheading "b" on page 4 of 10 of the written plan indicates that if the fire is not in their area, staff is to "continue normal operations." When and where staff is expected to respond using RACE is not clearly identified.



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Based on random observation during the survey walk-through, staff interview, and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

B. During a series of interviews held throughout the survey walk-through between February 22 and 25, 2010, the provider's staff was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 19.7.1.1. Further, during the survey walk-through, it was determined that existing records of such components were inaccurate for the reasons listed herein. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include, but are not necessarily limited to:

1. Occupancy classifications.

2. Portions of the building covered by an automatic sprinkler system. Surveyor 14290 notes that numerous Electrical Closets within the building are not covered by the automatic sprinkler system; these spaces were not identified as such on provided drawings.

3. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, and building separations. Regarding horizontal exits, Surveyor 14290 notes that each building story is shown on the provided drawings as being divided into several fire comparments. However, the provider's staff was not able to clarify which, if any of the fire barriers separating these fire compartments constituted horizontal exits. The provider's staff was thus not able to demonstrate compliance with:

a. 19.2.6.2.2. with respect to the maximum allowable travel distance to an exit.

b. 7.2.4.3.2. with respect to the protection of window openings within 10'-0" of locations where horizontal exits terminate at outside walls where such outside walls are at an angle of less than 180 degrees.

c. 9.6.2.1(1) and NFPA 72 1999 2-8.2.2., with respect to the provision of manual fire alarm pull stations within 5'-0" of doors in horizontal exits.

4. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, ventilation shafts, and linen and/or refuse chute shafts. Surveyor 14290 notes that not all shafts are indicated in the same manner on the provided drawings.

5. Smoke barrier walls and areas (in square feet) of smoke compartments. Surveyor 14290 notes that no smoke barrier walls are shown on the provided drawings. The provider's staff was thus not able to demonstrate compliance with 19.3.7.1. with respect to:

a. The maximum allowable area for smoke compartments.

b. The maximum allowable travel distance from the most remote point of a smoke compartment to a door in the smoke barrier wall.

6. Exit access corridors and designated corridor walls.

7. The limits and areas (in square feet) of all suites. Surveyor 14290 notes that:

a. Numerous portions of the building appear to constitute suites as defined by 19.2.5., but are not shown on the provided drawings as such (also refer to K-017, K-018, K-038, K-042, and K-072). Portions of the building which appear to constitute suites, but are not so identified include:

1) Fourth Floor:

a) Office Unit including Office 4300.

b) Caesarian Section Unit which includes Passage 4280.

c) The Neonatal Intensive Care Unit, which was identified by the provider's Project Architect, during an interview held on the morning of February 24, 2010 as constituting a single suite excluding the Locker Rooms and NICU 4331.

2) Second Floor:
a) Radiology Suite which includes Passages 2286, 2339, and 2343.

b) Imaging suite which includes Work Area 2477.

c) Cardiac Cath Suite which includes Work Area 2199.

d) Pediatric Heart Unit which includes Office 2105.

e) Office Unit which includes Office Area 2201.

f) Patient Treatment Unit which includes Office Area 2200.

3) First Floor:

a) Administrative Unit which includes Conference Room 1310.

b) Administrative Unit which includes Office Area 1400.

c) Nursing Administration Unit which includes Office Area 1500.

d) Several other possible suite locations on the south side of the building, east of Lobby 1000.

4) Concourse Level Rehabilitation Services Unit.
B. Suites are shown on the provided drawings which either do not constitute suites or do not comply with applicable codes as suites (also refer to K-017, K-018, K-038, K-042, and K-072). Locations observed include:

1) Seventh Floor Intensive Care Unit.

2) Third Floor Surgical Department Suite.

3) First Floor Emergency Department Suite.

8. Hazardous areas and their fire resistance ratings.

9. Locations of any special locking devices.

10. The locations of any special fire protection elements such as fire shutters or window protection.

11. Rolling fire doors or special protection components.

12. Exits.

Based on random observation during the survey walk-through and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During a series of interviews held throughout the survey walk-through on February 25, 2010, the provider's staff was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 21.7.1.1. Further, during the survey walk-through, it was determined that existing records of such components were inaccurate for the reasons listed herein. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include, but are not necessarily limited to:

1. Building construction types.

2. Occupancy classifications.

3. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, and building separations. Regarding horizontal exits, Surveyor 14290 notes that the First and Second Floors are shown on the provided drawings as being divided into at least 2 fire comparments. However, the provider's staff was not able to clarify which, if any of the fire barriers separating these fire compartments constituted horizontal exits. The provider's staff was thus not able to demonstrate compliance with:

a. 21.2.6.2. with respect to the maximum allowable travel distance to an exit.

b. 7.2.4.3.2. with respect to the protection of window openings within 10'-0" of locations where horizontal exits terminate at outside walls where such outside walls are at an angle of less than 180 degrees.

c. 9.6.2.1(1) and NFPA 72 1999 2-8.2.2., with respect to the provision of manual fire alarm pull stations within 5'-0" of doors in horizontal exits.

4. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, ventilation shafts, and linen and/or refuse chute shafts.

5. Smoke barrier walls and areas (in square feet) of smoke compartments. Surveyor 14290 notes that no smoke barrier walls are shown on the provided drawings. The provider's staff was thus not able to demonstrate compliance with 21.3.7.2. with respect to the division of those building stories which constitute ambulatory health care occupancies into at least 2 smoke compartments.

6. Hazardous areas and their fire resistance ratings.

7. Locations of any special locking devices.

8. Exit Passageways. Surveyor notes that Corridor 1012 is shown as an exit passageway serving Exit Stair S-1; see K-033.

9. Exits.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2.

Findings include:

A. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar year 2009, fire drills for the following quarters/shifts were conducted at the similar times listed [all Third Shift (11:00 PM to 7:00 AM):

1. 5:00 AM (1st Quarter) 03/13/09

2. 4:00 AM (2nd Quarter) 06/05/09

3. 4:00 AM (3rd Quarter) 09/18/09

4. 5:00 AM (4th Quarter) 12/31/09

B. The fire drill report did not include any information as to the staff being able to hear the announcements and or alarms.

A) The Hospital has an existing fire alarm system with a staff notification mode and a evacuation mode. The staff notification mode is labeled as a "pre-signal system". However, it is not a pre-signal system as defined by NFPA 72. The staff notification mode is designed to notify hospital personnel of an activation of the fire alarm system throughout the building via an audible chime code alarm and by red visual devices.

There is also a new addressable fire alarm system that has been installed throughout the facility, roughly parallel to the exiting fire alarm system. Although this new system is mostly installed and functional, the installation is incomplete. The new system has not been tested and has not been approved for use. Some supervisory and/or alarm functions may be tied to the new system and not to the existing system.

Specific interim life safety measures have been required for any and all deficiencies relative to either system.

1. The existing fire alarm system is not installed and maintained in accordance with NFPA 101, NFPA 25 and NFPA 72:

a. Fire alarm pull stations on the 9th, 10th
and 11th Floor mechanical spaces do not
function in accordance with NFPA 72.
During testing on 02/24/10, the fire
alarm pull stations on the floors
indicated failed to activate fire alarm
chimes and visual devices on every floor
of the Hospital

b. Fire alarm chimes on multiple floors and
multiple locations are barely audible or
cannot be heard at all.

c. Corridor doors, suite boundary doors,
required fire rated doors with automatic
opening functions are not disabled and
the doors to not close to latch, upon
activation of the fire alarm system.
Locations include but are not limited to:

two pairs of fire doors for 6 West

Corridor door to 3rd Floor PACU (3584)

d. Multiple doors that are part of a required
the means of egress have locking devices
with delayed release. These doors to not
release immediately upon activation of
the fire alarm and sprinkler system in
accordance with 7.2.1.6.1. Example:
4th Floor door to Stair # 3.

2. Basement Level C 900: These is a smoke detector in this space that is mounted four feet below the deck above.



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Based on random observation during the survey, not all the building fire alarm system are installed or tested in accordance with 19.3.4. Findings include:

B. Based on record review and interview, the facility failed to provide complete documentation of smoke detector testing in accordance with LSC Sections 9.6.1.3 and 19.3.4.1 and NFPA 72, 1999 Edition. During record review it was determined that the facilities testing company (Siemens) has not conducted or provided documentation as to when the last Sensitivity Test was conducted. The report will need to indicate the manufacture's range, devices physical location and if the individual detectors "pass" or "failed." The documentation failed to provide a test to confirm that all of the smoke detectors operated within the manufacture's activation range.

C. Fire Protection Company (Cybor), 7/30/09 report item#18, states: "Please note that the pressure switch and air maintenace device on 1st floor south building MRI preaction system has a history of unreliability and should be monitoed closely. If issue persist, we highly recommend making repairs to help maintain system integrity. Inaccurate / unreliable air gauge on south penthouse dry pipe valve. Please note max fire pump discharge psi exceeds rated max psi of some fittings/components. Please note the AMD on the south concours zone#2 is showing signs of unreliability and may require future replacement. Please note the control valves for the 1st floor south loading dock dry valve and the penthouse south dry valve have packings that are near the end of their adjustment and may require repack/replacement in near future." The facility could not produce any plan of action, purchase order, or work order to verify if all issues related to this report have been/or will be corrected.

A) Based upon random observation the surveyors find that sprinklered systems are not installed and maintained in accordance with NFPA 13:

1) Electrical Rooms typically are not sprinklered and instead use an exception under NFPA 13 that requires a two hour fire rated enclosures for each unsprinklered electrical room. A number of electrical rooms do not comply with the exception under NFPA 13:

a) A number of these electrical rooms are
used for storage (strictly prohibited
unless the rooms are sprinklered).

Basement Level Sub Station C905 -
storage in unsprinklered electrical room

Basement Level C904 - storage in
unsprinklered electrical room

Basement Level C904A - storage in
unsprinklered electrical room

Basement Electrical Room C1 has
visqueen on the floor.

b) The two hour enclosure for some rooms
is incomplete. Examples:

i) 9th Floor Electrical Rooms have
pairs of 1 1/2 hour fire doors. These
doors also have a transom panel above
the doors that are only 1/2" to 3/4" thick.
There is no evidence that indicates that
the transom panels constitute either a 1
1/2 hour or a two hour fire barrier in
accordance with NFPA 80 and/or 8.2.3
of NFPA 101.

ii) Basement Electrical Closet C622A
is not sprinklered. The room has a 1 1/2
hour fire doors but the room has no
fire enclosure walls above the ceiling.

iii) Communication Closet (C263) this
triangular shaped room has no sprinkler
protection. The room has not ceiling and
is open to the adjacent ceiling cavities
(which are not sprinklered)

2) Sprinkler heads are not installed in accordance with NFPA 13:

a) 10th Floor: Storage Room P101A,
inside the 10th Floor Elevator Machine
Room.

b) 10th Floor (or possible 9th Floor):
There is a north door from Stair: 4 that
provides access to the Mechanical
Room. Sprinkler protection is not
provided in the Southeast corner of this
space (space includes a Fitter's Cabinet)
or the sprinkler heads above are blocked
by ductwork.

c) Basement - Dietary Walk-in Freezer
# 2 has storage on the center shelves
that are closer than 18" below the
sprinkler heads in this space.

d) Basement - Dietary: Walk-in Unit C420
has a missing access panel high on the
back side of the unit. The Kitchen is
open to the unsprinklered space above
this walk in unit

3) Sprinkler protection (and any fire alarm detection devices) are compromised by missing of ceiling tiles in lay-in ceilings. Locations include but are not limited to:

a) Basement Level

Ë446 - Linen Holding Room

Data Room ( with raised floor) inside
C268

Room C268 has sprinkler heads with
"hats" the heads are installed too far
below the ceiling above.

C250

Janitor's Closet (w/ Fire Zone 1-1-6
Room C 3) on door

4) The Basement Level Islet Lab is protected with a pre-action sprinkler system. The entrance vestibule and the viewing space both appear to be protected by this pre-action system but these two spaces lack detection devices that will charge the pre-action system. A system narrative for how this pre-action system functions was not available.

5) Basement Level Data Center C250 is protected by a pre-action sprinkler system. The room was observed with multiple detection devices including three devices side by side. A narrative for the function of these devices and how this pre-action system functions was not available.



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

B. Materials were observed being stored less than 18" below sprinkler heads as prohibited by NFPA 13 1999 5.6.6. Locations observed include 3rd floor, Tissue Processing -Gross (3114B) Sprinkler located above a work station hood and is not provided with 18" clearance.

C. Rooms or spaces were observed at which ceiling tiles or surfaces were observed to be missing or damaged compromising sprinkler coverage as prohibited by NFPA 13, 1999 5-6.4.1.1. Locations observed include:

1. 7th floor, Medication Room (7544E) the ceiling tiles were not seated into the frame due to low voltage wiring obstruction.

2. 7th floor, Janitors Closet (726W) the plaster ceiling was observed to contain a penetration that was not sealed.

3. 7th floor, Soiled holding - Biohazards (7106W) ceiling tiles are not setting into the frame, breaching the ceiling plane to cavity above.

4. 3rd floor, Cytology Screening Room (3135 A-C) Several ceiling tiles were damaged, including holes and missing corners.

5. 1st floor, Triage, ceiling tiles were missing.

6. 1st floor Main Entrance Lobby, the enclosed vestibule / airlock was not provided with sprinkler protection. This vestibule is like a box sitting in the lobby area, and is not constructed to the ceiling deck above. The space above the vestibule was not provided with sprinkler protection either.

7. 1st floor, Storage (1133) off of main lobby, is not provided with sprinkler coverage.

D. The exterior canopy for ER, under which ambulances were parked was observed to lack sprinkler heads required by NFPA 13, 1999 5-13.8.2.

E. Sprinkler heads were observed that are are not being maintained in accordance with NFPA 25, 1998. Conditions observed include:

1. 7th floor Charting Room (75310) contained a sprinkler head recessed into the ceiling cavity, and not extend past the ceiling tile plane.

2. 7th floor Stair #2, fireproofing from the roof/deck is visible on the sprinkler head.

F. Sprinklers were not installed in the following locations as required for a fully sprinkled facility.

1. 7th floor, all patient room closets. The sprinklers located within the patient room were not located to include accurate coverage of the patient room closets.

2. 7th floor, Oxygen Storage (751EA) at the nursing station is a 2 hour rated enclosure based on the drawings, but the room did not contain sprinkler protection.

3. 5th floor, all patient sleeping room ardrobes. The sprinklers located within the patient room did not appear to be located to include coverage of the patient room closets.


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G. Patient Sleeping Room Wardrobes were observed that are not covered by the automatic sprinkler system as required by NFPA 13 1999 5-1.1(1). Locations observed include:

1. Eighth Floor, Patient Sleeping Rooms west of Column Line 8.

2. Sixth Floor, Patient Sleeping Rooms east of Column Line 12.

H. Ceiling tiles were observed to be missing in Eighth Floor Storage Room 870E, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1.

I. Electrical Closet 665WA was observed to be open to the ceiling cavity, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1.

J. Sprinkler heads were observed that are missing escutcheon plates as prohibited by NFPA 25 1998 2-4.1.8. Locations observed include:

1. Eighth Floor Medication Room 843E.

2. Second Floor Corridor 2310, near Bridge to Outpatient Care Center.


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Based on direct observation the surveyor finds the facility failed to provide:

K. Automatic sprinkler protection for the high voltage switchgear located outside the protected electrical switchgear room enclosures. Sprinkler heads have been removed from over and around the area where high voltage switchgear is installed within the air handling equipment room. Combustible storage is located within the footprint where the sprinkler protection has been removed. The installation does not meet the exceptions listed in NFPA 13, 1999, 5-13.11 for elimination of sprinkler protection.

A) Based upon random observation, the surveyor finds that manual fire extinguishers are not maintained in accordance with NFPA 10:

1) The provider documents monthly visual inspections with a written procedure that requires a visual inspection and bar code scan to document the inspection. Most fire extinguishers have a unique UIC bar code on each device. Some of the fire extinguishers observed did not have an individual bar code. The provider was not able to demonstrate how the fire extinguishers that lacked individual bar codes were inspected and documented.

A) Based upon random observation and document review, the surveyors find that fire dampers and/or fire/smoke dampers are not installed and maintained in accordance with NFPA 90A.

1) According to the provider and based upon documentation, fire dampers were tested, cleaned and maintained in 2007 for the 949 Building (Main Hospital). The documentation identifies dampers that could not be accessed, dampers that need cleaning or replacement, dampers that are broken etc.

The provider had no documentation that indicates when and how the above items have been corrected.



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

Findings include:

B. 3rd floor surgery electrical closet (3520) defined as a 2 hour rated room on the drawings. This unsprinkled closet contained a duct penetration that was not provided with a fire damper as required for a 2 hour rated enclosure.



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C. A series of perimeter ventilation shafts were observed which connect the Eighth through Fourth Floors between pairs of Patient Sleeping Rooms (as well as other perimeter rooms) in the Hospital. Based on document review, it was determined that there appear to be 42 such ventilation shafts, all serving below-window induction units. Penetrations of the ventilation shafts by ductwork (typically 1 such penetration for each pair of rooms on each building story) were observed to lack fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.1.1.

A) Based upon direct observation and review of documentation for the past 14 months, the surveyor finds that kitchen hood suppression systems are not installed and/or maintained in accordance with NFPA 17A and NFPA 96:

The facility has three hood suppression systems that are required. Two are in the 1st Floor Cafeteria Serving area and the 3rd is in the Basement Dietary Department main cooking line. All system are ANSUL wet chemical systems. The 1st Floor hoods have removable grease filters while the Basement has an engineered grease extraction system

1) The 1st Floor suppression systems each has a fryer and a flat grill under the hoods (they have the same equipment. The hoods, the ANSUL pull station, the ANSUL "box" with the suppression tank and the documentation all lack a unique identifier or reference for each hood. While some of this is apparent, some of it is not apparent and should be clearly identified in accordance with the above referenced standards.

2) The testing documentation for the last two semi-annual inspections:

a) does not identify the type of equipment and the manufacturer of the equipment protected under each hood.

b) The forms used by the outside contractor to document semi-annual inspection is very detailed and is comprehensive. However, there are conflicts or blank areas to be checked that are not. Some of the items marked "NA" need further written explanation. Item # 47 on the form indicates that shut trip breakers are not required, yet other parts of the form indicate that shut trip breakers are installed and were tested.

c) Line # 49 on the forms list a location where the contractor can identify where shut trip breakers are located; a location is not identified.

d) The semi-annual testing documentation of 9/21/09 for a first floor kitchen hood indicated that there hole in the hood that needs to be patched. The provider was not able to indicate when and how this item was corrected.

e) The documentation for the Basement hood suppression system dated 9/21/09 indicates that the suppression system does not comply with the manufacturer's recommendation but does not indicate what the issues were. It also indicates that the suppression system does not comply with U L 300.

The surveyor finds that the system was modified on 1/30/10 to comply with U L 300; however full documentation and retesting certification of the entire system was not available on site.

3) All hood suppression system have electrically fueled appliances that must be disconnected from the fuel source upon activation of each system. Shut trip breakers are installed and tested for each system. Each system has an electrical panel with circuits that identify the appliances on that panel. Below each panel is a main shunt-trip device that disconnects all or part of the panel directly above it.

a) The shunt-trip device below each panel is not clearly identified and also does not clearly identify what is disconnected (entire panel above, individual circuits, etc).

b) The electrical panel above each shunt-trip device does not accurately identify the circuit and equipment supplied from the panel. Some of the equipment identified on the panels are no longer installed.



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Based on direct observation, the surveyor finds:

B. The installation of the kitchen grease duct and utility fans within the 9th floor mechanical penthouse are in non-compliance with NFPA 96, 1998.

1. The connections for the kitchen hood exhaust ducts to the utility fan sets are flexible connections prohibited by NFPA 96, 1998, 5-1.3.

2. The shaft enclosure for the grease ducts from the basement through the floor of the 9th floor mechanical penthouse is not vented to the exterior of the building. (NFPA 96, 4-7.1)

3. The grease duct shaft enclosure within the mechanical penthouse is not continuous to the exterior of the building. The grease ducts penetrate the top of the shaft unprotected to the exterior of the building as prohibited by NFPA 96, 4-7.1.

Based on random observation during the survey walk-through and staff interview, 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. Carts and equipment 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. Eighth Floor:

a. Visitors' Elevator Lobby, gurney and wheelchair.

b. Corridor 8143, 2 wheelchairs.
2. Sixth Floor:
a. Corridor 6132, 2 work stations on wheels.

b. Corridor 6135, 2 work stations on wheels.

c. Corridor 6139, 2 work stations on wheels and 1 wheeled equipment pole.
d. Isolation Vestibule 682E, work table obstructs sole access from Patient Isolation Room.

3. Fourth Floor:

a. Corridor 4052, portable x-ray machine.

b. Corridor 4127, wheeled equipment pole.

c. Corridor serving Office 4300, audio-visual equipment and furniture (also refrer to K-048).

d. During an interview held at the site on the morning of February 23, 2010, the Caesarian Section Unit Nurse Manager stated that gurneys are stored in Corridor 4280, as prohibited by 19.2.3.3. and 7.1.10.2.1., while cases are underway (also refer to K-048).

4. Second Floor (also refer to K-048):

a. Radiology Unit Corridors 2286, 2339, and 2343, work areas and equipment.

b. Imaging Unit Corridor 2477, work stations and equipment.

c. Cardiac Cath Unit Corridor 2199, work stations and equipment.

d. GI Unit Corridor 2309, equipment.

e. Office Unit Corridor 2201, work stations.

f. Treatment Unit Corridor 2200, work stations.

Based on random observation during the survey walk-through, not all Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended. 19.7.5.5.

Findings include:

A. Floor 7, corridor wheelchair storage niche (759W) contained a recycle cart exceeding the 32 gallon capacity.

B. Floor 5, corridor niche (522E) contains two carts, exceeding the 32 gallon capacity and blocking access to electrical panel 5L3C.



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C. A trash receptacle with a capacity in excess of 32 gallons was observed being stored in Fourth Floor Corridor Alcove 459W as prohibited by 19.7.5.5.

A) From observation, the surveyor finds that oxygen is stored in the Basement Level I V Fluids Storage Room (C985). The oxygen tanks were stored closer than 5'-0" to combustible and do not comply with NFPA 99 - 1999.



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

Findings include:

B. 5th floor, clean holding room (567W), contains 7 oxygen tanks that were not provided with the 5'-0" clearance from combustibles as prohibited by NFPA 99, 8-3.1.11.2.c.2 for sprinkled portions of the facility.


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C. Medical gas tanks were observed being stored, in Eighth Floor Storage Room 830E, that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2).

(Information 02/23/2010): Based upon observation and personnel interviews, the surveyors find: The UIC West Plant is made up of two buildings; both are located on the south side of Taylor Street, directly across the street from the Hospital:

1) The 952 Building which houses four, diesel fired emergency generators.

2) The 921 Building which includes a very large and complex electrical distribution system for the UIC West Campus and.

a) It houses three, high pressure, gas fired,
co-generation power, turbine generators
that are designed to provide normal
power to the UIC West Campus and
UICMC. The co-gen systems produce
steam as a by product that is used as a
source of steam for the UIC
West Campus and the UICMC (and
Rush University Medical Center).

b) The 921 Building also houses multiple
peak load generators that are designed to
supplement normal power.

c) The 921 Building houses multiple
chillers

d) The 921 Building houses 7 large boilers
that are designed to provide steam for
heat, humification and sterilization for
the UIC West Campus and the UICMC
(and Rush University Medical Center).
Of the seven boilers only Boiler # 5 and
6 were operational. (Boilers 1 through 4
have been decommissioned. Boiler 7
is non-operational and is scheduled
for replacement.

A) (Modified 02/22/10): The Hospital does not comply with NFPA 99-1999. During a complaint investigation on December 9, 2009, the surveyors observed that the Hospital lost ability to produce heat, hot water and humidification. Further, the hospital lost the ability to produce steam for sterilization. This occurred on three separate dates, 12/04/09, 12/07/09 and 12/08/09.

1) The surveyors note that these events took place because the hospital lost steam pressure from the UIC West Plant that is located just south of the Hospital. The West Plant has two systems that produce steam. Both systems failed due an internal, normal power, distribution failure. Neither system is backed up by an emergency power that is installed and/or maintained in accordance with NFPA 70, NFPA 99 and NFPA 110. The lack of emergency power for the system(s) that provides heat to the Hospital's operating rooms, delivery rooms, recovery areas, intensive care areas, nurseries, etc. does not comply with NFPA 99 - 1999, 3-4.2.2.3 (e) 1).

a) The existing boilers are not connected to
an emergency power source.

b) The co-gen turbine generators are
designed only to run and provide steam
when normal power is available. This
system is not designed to function under
emergency power or an alternative
power source when normal power is
interrupted.
.
2) Further, the surveyors note that any interruption of normal power in the West Plant shuts down all of the steam producing equipment (new system and old system) in the plant. A power failure occurred on the evening of Monday, December 7, 2009. Normal electrical power was interrupted to the UIC West Campus, to UIC Medicare Center and to the steam producing equipment in the West Plant. This arrangement does not comply with 3-4.2.2.3 (e) 1) (NFPA 99 - 1999).

3) Deleted 02/25/10

4) (02/23/10): A temporary, 1 Megawatt, emergency power system (mobile generators) is kept on site at the West Plant as a back up system. This back up system is not currently connected to the building and is not currently being used to provide normal or emergency power to to the West Plant. It is available to provide power to the existing old boilers (Boiler # 5 and 6) if normal power fails, as an interim measure.



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By direct observation the surveyor finds:

A. The generator for supply of emergency power to the fire pump located in the 920 building is not provide with a remote manual emergency stop station. (NFPA 110, 1999, 3-5.5.6)

B. The four emergency generators, located in the 952 building, serving the essential electrical system for the Medical Center, are not provided with remote alarm annunciators at a constantly attended work station as required by NFPA 99, 1999, 3-4.1.1.15 (b).

Based on general observations it was observed in the Basement mechanical room that indirect waste piping from the "clean drain" was not provided with an air gap at the floor drain. As required by the Illinois Plumbing Code 890.1040.

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. 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.

Surveyor 07113:

1. The provider lacks interim life safety measures for the deficincies observed (refer to K-051).

B. Basement Level Carpenter Shop: Access was not provided. Surveyor could not confirm one hour fire rated enclosure for a high hazard area and sprinkler head spacing for high hazard could not be confirmed.

C. CFR 482.41(a) (A701 - Maintenance of Physical Plant): The condition of the physical plant and the overall hospital environement must be developed and maintained in such a manner that the safety and well-being of patients are assured. (this item may not be corrected until A701 is corrected - form 2576b required by surveyor).


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By direct observation the surveyor finds:

The facility failed to provide a means for providing fuel for heating should the utility supplied fuel become interrupted as required by:

A703 CFR 482.41(a)(2) There must be facilities for emergency gas and water supply.

(The hospital must have a system to provide emergency gas and water as needed to provide care to inpatients and other persons who may come to the hospital in need of care. This includes making arrangements with local utility companies and others for the provision of emergency sources of water and gas. The hospital should consider nationally accepted references or calculations made by qualified staff when determining the need for at least water and gas. For example, one source for information on water is the Federal Emergency Management Agency (FEMA).

(Emergency gas includes fuels such as propane, natural gas, fuel oil, liquefied natural gas, as well as any gases the hospital uses in the care of patients such as oxygen, nitrogen, nitrous oxide, etc.)

(The hospital should have a plan to protect these limited emergency supplies, and have a plan for prioritizing their use until adequate supplies are available. The plan should also address the event of a disruption in supply (e.g., disruption to the entire surrounding community).

A) From random observation, the surveyors find that electrical installations and materials do not comply with NFPA 70:

1) Access to electrical panels or switchgear was blocked:

a) Basement Storage Room C508: Storage
in front of switchgear.

2) Electrical extensions cords are used for permanent power

a) Basement Level Midnight Pharmacy
Hood - yellow cord on floor

3) Basement Level C900:

a. There is a black cable that is strapped to
the electrical conduit (overhead) in this
area. The provider did not know what
the black cable was or how it complies
with NFPA 70.

b. There is an electrical panel in the
Northwest corner of the electrical space.
The panel lacks identification. Some
circuits lack identification and access to
the panel is blocked by storage. and by a
table with a vise.

c. There are multiple electrical extension
cords strapped to electrical conduit in
this area.



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Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

B. 7th floor, Staff Break Room (770E) contains electrical panel 7LPT-1. The directory numbering and referencing does not match the actual numbering on the circuit breakers in use.

C. 3rd floor, Surgery (OR #12), the surface mounted wire chase is missing a cover or protective plate.



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D. Critical care patient beds were observed at which electrical receptacles served by the building emergency electrical system are not labeled as to panel and circuit number as required by NFPA 70 1999 517-19(a). Locations observed include (all Sixth Floor):

1. Patient Sleeping Rooms within designated Intensive Care Suite.

2. Patient Sleeping Rooms in Intensive Care Unit north of Suite.

A) Based upon random observation and personnel interview, the surveyors find all elevators (ten of ten) lack automatic recall (floor and alternate floor) from activation of the Old Existing Fire Alarm System (see also K051) in accordance with ANSI A17.3.

The surveyor notes that automatic recall may be functional from the new addressable Fire Alarm System that is being installed. However, this new system is currently incomplete and not tested. Elevator recall functions are currently by-passed on this new system.

This citation does not apply to dumbwaiter systems or to freight elevators.

A) Based on random observation during the survey walk-through, the surveyor finds that not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. Portions of steel beams were observed with missing fire proofing. Locations observed include:

1) 4th Floor NICU Room 4335

2) Basement Level

a) Stair # 7 has an access panel in the stair
enclosure, one half level up from the
Basement. There is a steel beam above
the space behind this access panel that is
missing fire proofing on a portion of the
beam.

b) C906 - Mechanical Space: fire proofing
is missing from the bottom flange of a
steel beam in the southeast corner of this
space.

c) There is a pair of fire doors next to
Room C288. Fire proofing is missing from a
beam above the ceiling, west of the
doors.



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Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

B. 5th floor, above the cross corridor doors by "Tel Closet" 5102W, portions of the steel structure were observed not covered by fire proofing material in accordance with the designated building construction type.

C. 1st floor, ER ambulance canopy contains metal columns that support this roofing system and are not enclosed or provided with fire proofing material.



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D. Portions of the steel structure were observed that are not covered by fire proofing materials in accordance with the designated building construction type. Locations observed include:

1. Eighth Floor:
a. Data Closet 8106W.

b. Immediately outside Exit Stair 8-S4.

2. Fourth Floor Elevator Machine Room 4210A.

A) From random observation, the surveyor finds that spaces open to corridors do not comply with the exceptions under 19.3.6.1:

1) The Basement Level C100 Rehabilitation Services (Inpatient/Outpatient) has patient treatment bays that are open to the adjacent corridors or aisles. This condition does not comply with 19.3.6.1. Based upon this, the surveyor finds that this space is very likely intended to be a health care suite (treatment suite). No information is provided that identifies this space as a suite (see K048). The size and boundaries of the suite are not clearly identified. How two remote paths of egress are provided in accordance with 19.2.5.3 are not identified (see also K038 and K042).



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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:

B. Staff work areas which are open to the corridors were observed which are not provided with smoke detectors required by Exception 1. [subpart(c)] to 19.3.6.1. (also refer to K-048). Locations observed include (all Second Floor):

1. Radiology Unit Work Areas as part of Corridors 2286, 2339, and 2343.

2. Imaging Unit Work Areas as part of Corridor 2477.

3. Cardiac Cath Unit Work Areas as part of Corridor 2199.

4. Office Unit Work Areas as part of Corridor 2201.

5. Treatment Unit Work Areas as part of Corridor 2200.

C. Treatment rooms were observed that are open to corridors as prohibited by 19.3.6.1. (also refer to K-048). Locations observed include (all Second Floor):

1. Several Radiology Rooms served by Corridors 2286, 2339, and 2343.

2. Prep/Recovery Room 2125.

Based on random observations during the survey walk-through, not all doors in the exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. 7th floor, 7W0T Transplant ICU (can not be a suite) and contains doors in the exit access corridor that were observed not to be equipped with positive latching hardware as required by 19.3.6.3.2.

1. Room 735W

2. Room 736W

3. Room 737W

4. Room 738W


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B. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. Locations observed include:

1. Sixth Floor:

a) Patient Isolation Room 677WA.

b) Patient Isolation Room 677WB.

2. Fourth Floor Sub-Sterile Room 4272, 2 doors to adjacent Operating Rooms (also refer to K-048).

3. Second Floor Radiology Suite which includes Corridor 2286, several Treatment Rooms (also refer to K-048).

C. The door to Fourth Floor Sonogram Room 4201 was observed to be obstructed in manner that will prevent the door from closing, as required by 19.3.6.3.2., by a curtain and by items hanging from the door latchset.

D. A dutch door was observed, at Second Floor Procedure Room 2313, which does not comply with 19.3.6.3.6. because:

1. The upper leaf was observed to not positively latch to the lower leaf (slide bolt only).

2. The assembly was observed to not include a bevel, rabbet, or astragal at the meeting edge.

A) Based upon random observation ,the surveyor finds that vertical opening and protection of vertical openings are not installed and maintained in accordance with Section 8.2.3.2 and 8.2.5:

1) 9th Floor - Stair # 4: The 1 1/2 hour access panel in the stair wall is not self closing (spring for access panel was missing).



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

Findings include:

B. Openings were observed in ventilation or other shafts that are not sealed against the passage of fire as required by 8.2.5.4. Locations and types of openings observed include (all Eighth Floor):

1. Break Room 870E, opening in designated 2 hour fire rated shaft wall covered with single layer of drywall.

2. Lounge 860E, unsealed pipe penetration in designated 2 hour fire rated shaft wall covered with single layer of drywall.

C. The fire rated access panel to the Elevator Shaft from Fourth Floor Elevator Machine Room 4210A was observed to not be self-closing, as required by 8.2.3.2.3.1(1), because:

1. The spring was observed to have been removed.

2. A pair of wires extends through the access panel to the Elevator Control Panel, thus preventing the access panel from closing.

Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintain the fire resistive assemblies in accordance with 39.3.1.1.
Findings include:

A. Random (observed at 8th and 6th), the pipe shafts located in the elevator and stairs are not sealed. The shaft enclosure contained a rated door but it was installed directly to the open CMU block. The installation observed is not a UL approved method.

1. The rated door to the shaft was observed to not be a self closing and latching door, since the "spring" has been removed.

Based on random observation during the survey walk-through, not all doors to exit enclosures are held open by devices arranged to automatically close the doors as required by 19.2.2.2.6.

Findings include:

A. The Sixth Floor door to Exit Stair 1 was observed to be held open by a chair as prohibited by 19.2.2.2.6. and 7.2.1.8.2.

A) From random observation, the surveyors find that hazardous areas are not enclosed in accordance with 19.3.2.1, and/or 8.4.1.1 and hazardous areas are not separated from other use areas.

1) The Basement Level (Concourse) has a 12' wide, Main Corridor that extends east and west the length of the building. The Basement Level lacks a separate holding area for soiled linen, soiled waste and bio-hazard waste. The 12' wide Basement Corridor is used to stage and hold equipment, supplies, and furniture, along with soiled linen carts, waste carts and bio-hazard waste. The west end of the corridor by the end of the day is filled with soiled materials carts to the point that access to the west stair (Stair # 2) becomes blocked.

a) The 12' wide corridor is a required
means of egress for multiple office and
service areas at this level (but not for
health care). The means of egress for
such areas are prohibited from exit
through this area of higher hazard as
prohiited by 39.3.2.1. and 8.4.1.1.

2) Basement Level:

a) Chemical Storage C444: the door to this
room is not self closing

b) The Dumbwaiter Machine Room (624)
has a hole in the enclosure wall at a
junction box.



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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:

B. Hazardous areas covered by a sprinkler system were observed at which doors are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

1. Eighth Floor Patient Belongings Room 841E.

2. Fourth Floor Clean Storage Room 4261.

3. Second Floor File Storage Room 2504.

Based on random observation during the survey walk-through and document review, not all laboratories employing quantities of flammable, combustible, or hazardous materials are protected in accordance with NFPA 99.

Findings include:

A. 3rd floor Lab:

1. The Lab is not indicated on the master life safety plans as being enclosed by 1 hour rated construction as specified by NFPA 99, 10.3.1.1.
2. Room 3134A, contains storage of wax blocks that are not being stored in a rated enclosure and/or room.

A) Exit enclosures including exit stair are identified on documents as having two hour fire rated enclosures. These enclosures are compromised and do not comply with 7.1.3.2, 7.1.3.2.1 e) and/or 7.2.2.5.3.

1) Stair # 4 has an IS Shaft immediately next to the stair enclosure. The common wall between the two vertical openings is a 4" concrete block wall with a space and then another 4" concrete block wall.

a) The stair enclose at the Basement Level
has a fire rated access panel in the lower
wall. The hose cabinet above the access
panel penetrates one layer of 4" block
and is not fire rated. There is a hole in
the 4" block of the IS Shaft behind the
access panel. It could thus not be determined
that a complete 2 hour fire barrier exists
between the IS Shaft and the Exit Stair.

2) Stair # 7 has an access panel in the stair enclosure, one half level up from the Basement. This access panel is positive latching and self closing but is not a fire rated access panel.

3) Stair # 2 - Basement Level: There is a hole in the south soffit of the stair, under the landing. Also, there a black cable strapped to an electrical conduit that runs through the stair enclosure. The cable and possible the conduit are not permitted under 7.1.3.2.1 e).

4) Stair # 1 - Basement Level: A cart was left in this stair, under the landing.



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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:

B. 5th floor, Stair #4 (5-S4) the shaft adjacent to the stair well contains sprinkler piping that penetrates the stair enclosure and is not sealed on the shaft side to maintain the 2 hour rating.

C. Floor #3, Stair #6 the door to the stairwell did not close to the latched position without assistance.



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D. A portion of the concrete block above the door at Eighth Floor Exit Stair 8-S4 was observed to be missing, thus the wall is not sealed against the passage of fire as required by 8.2.5.4. and 8.2.3.2.4.2.

E. At the Concourse Level of Exit Stair 1, 3 duct penetrations were observed which lack fire dampers required by 8.2.5.4. and NFPA 90A 3-3.1.1.

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

Findings include:

A. The pair of doors between First Floor Corridor 1012 (which is shown on provided drawings as an exit passageway) and Waiting Room 1011 was observed to not carry a minimum fire resistance rating of 1-1/2 hours as required by 8.2.3.2.3.1.(1) (also refer to K-048).

B. First Floor Corridor 1012, which is shown on the provided drawings as an exit passageway for Exit Stair S-1, was observed to:

1. House 2 Elevators as prohibited by 7.1.3.2.3.

2. Contain an opening from Janitor Closet 1012A, which constitutes a not normally occupied room, as prohibited by 7.1.3.2.1(d).

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. (modfiied 07/02/10): The Exit Stair Enclosure was observed to house, at all building levels, the Elevator Lobby as prohibited by 9.4.7 This condition was observed at ;
1. The South Elevator/Stair.

2. The North Elevator/Stair.

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. 7th floor, Stair #3 (7-S3) a bed table tray was observed being stored in the exit stairs as prohibited by 7.2.2.5.3.


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B. Exit stairs were observed at which re-entry to the building is not permitted as required by 7.2.1.5.2., because re-entry can only be accomplished with the use of a key. Further, no signage was observed within the exit stairs which clarify to building occupants that re-entry is not permitted. This condition was observed at all building stories at the exit stairs listed below:

1. Exit Stair 1.

2. Exit Stair 2.

3. Exit Stair 3.

4. Exit Stair 5.

5. Exit Stair 6.

6. Exit Stair 7.

C. Exit stairs were observed that are not provided with signage within the enclosure that identifies the story, the top and bottom terminus, and the stair enclosure identification which is visible without entering the Exit Stair and closing the door. Locations observed include:

1. Exit Stair 1.

2. Exit Stair 2.

3. Exit Stair 3.

4. Exit Stair 4.

5. Exit Stair 5.

6. Exit Stair 6.

7. Exit Stair 7.

D. Exit stairs were observed at which utilities had been recently installed that are not related to the conditioning or operation of the stair, as prohibited by 7.1.3.2.1.e. Locations and utilities observed include (all Exit Stair 2):

1. Second Floor Landing, 3 conduits an 1 device served by a coaxial cable.

2. First Floor Landing, 1 conduit and junction box.

A) Based upon random observation, the surveyors find that exit paths are not provided and maintained as a protected path to a public way.

1) The Basement Level C100 Rehabilitation Services (Inpatient/Outpatient) appears to be a health care suite (patient treatment) (see K017 and K048). It has been evaluated as a suite under this tag. This suite currently has three identified means of egress out of it. One is to a corridor door that serve as the entrance to this unit. A 2nd path is directed to the South Stair (Stair # 5). The 3rd path from this unit is directed east into and through an area that was formerly a hydrotherapy area and part of the Rehab Unit.

a) A portion of the Hydrotherapy area has been turned into a workshop and storage area. This constitutes a change of use and the use is a hazardous area. This former Hydrotherapy area is not separated from the Rehab Department by one hour fire rated barriers in accordance with 18.3.2.1. The two pairs of doors that connect Hydrotherapy to the Rehab Department lack 3/4 hour fire rated doors with self closing and positive latching hardware (18.3.2.1). And the exit path is directed into and through this hazardous area (does not comply with 7.5.2.1) and is then directed through the Dietary Department (does not comply with 7.5.2.1).

b) There is a foyer between the former Hydrotherapy area and Dietary. The identified exit path from this foyer is north, into Dietary from Hydrotherapy and the Rehab Unit. This foyer has only one way out, to the north. Re-entry back into Hydrotherapy can be obstructed by a manual slide bolt on the door in that direction.

c) The "walk-in cooler/walk-in freezer corridor" north of the above foyer is a long, corridor like space with a door and exit sign to the north. As an exit access corridor, this space lacks two remote paths of egress and constitutes a 56' dead end corridor to the south. This space cannot use the hazardous area to the southwest (former Hydrotherapy) as a means of egress (7.5.2.1) and it cannot use a suite (Rehab) as a means of egress.

The pair of doors to the south lack signage indicating "Not an Exit" and the pair of doors to the north lack signage on the north side of the doors (inside the Kitchen area) indicating "Not an Exit".

2) Basement Level Dietary Department: The Kitchen has multiple walk-in coolers and freezers. Some of them have two doors. Many of the doors were observed to have padlocks. One means of egress from each walk-in unit is not maintained (without a padlock) in accordance with 7.2.1.5.

3) There is a north/south corridor-like-space (C292) that is currently being used for wheelchair storage. This space has a fire door that leads into Building 924. The door is locked. The door lacks a sign indicating that it is not an exit leading into building 924 (7.10.8.1)



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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:

B. Stair #2, 1st floor from cafeteria the stair discharges to the exterior at this level. The stairs continue beyond the level of exit discharge and are not equipped with in interrupter gate as required by 7.7.3.


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C. Dead-end corridors of excessive length were observed as prohibited by 19.2.5.10. (also refer to K-048). Locations observed include (all Second Floor):

1. Imaging unit Corridor 2477.

2. Cardiac Cath Unit Corridor 2199.

D. Second Floor Corridor 2314 was observed to lack 2 remote exits. required by 19.2.5.9., because no exit sign exit sign was observed at the south end of the Corridor (also refer to K-048).

E. The padlock for the accordion door serving Eighth Floor Storage Alcove 886EB was observed to be keyed differently than all other keys in the Psychiatric Unit; thus all staff does not carry the key to this space as required by Exception 1. to 19.2.2.2.4.

A) Based on observation, the surveyors find that the Basement Level C100 Rehabilitation Services appears to be a patient treatment area suite (see K038 and K048). It has three identified exit paths. The exit path to the east is not permitted and cannot be counted as an exit path (see K038). One exit path leads to an exit stair. This path to the stair can be counted as an exit path only if the primary exit path from the most remote point in the suite to a corridor door is less than 100' (19.2.5.8). The primary exit path does not comply with this section.



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Based on random observation during the walk-through, not all designated suites are provided with exits in accordance with 19.2.5.

Findings include:

B. 3rd floor, the designated OR Suite exceeds 10,000 square feet as prohibited by 19.2.5.7.

C. 1st floor, the designated ER suite exceeds 10,000 square feet in size as prohiibted by 19.2.5.7..

A) Based upon random observation throughout the Hospital, the surveyors find that Horizontal Exits and/or designated two and three hour fire barriers do not comply with 19.1.2.4, 19.2.2.5, 7.2.4, and/or 8.2.3 (where applicable):

1) Horizontal Exits are not clearly identified on the Life Safety Master Plans (see K048)

2) Basement Level C600: The pair of fire doors to this space has one leaf that does not close to latch.

3) Basement Level C900: The pair of fire doors to this space have an active/inactive leaf arrangement. The automatic flush bolts on the inactive leaf were disabled. The inactive leaf lacks positive latching hardware.

B) 10th Floor - Large Elevator Machine Room: The fire door opposite AHU S-1 does not close to latch. Air pressure keeps the door from closing automatically.



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Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

B. 5th floor, during the fire alarm testing the cross corridor doors to PEDs ICU did not close and latch because they were binding on the flooring material.


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C. The pair of doors in the designated 3 hour fire rated wall at the east end of Corridor 5053E were observed to not close upon activation of the building fire alarm system, as required by 7.2.4.3.8. and 8.2.3.2.3.1(1), because the doors are held open by the flooring material.

D. A pipe was observed to be embedded in the designated 3 hour fire wall at Electrical Closet 803W; thus the wall is not sealed against the passage of fire at that location as required by 8.2.3.2.4.2.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. Three pipe penetrations, through the designated 3 hour fire rated wall in Mechanical Equipment Room C405 (at the Steam Tunnel), were observed to not be sealed against the passage of fire as required by 8.2.3.2.4.2.

A) Based upon random observation the surveyor finds that illuminated exit signs or directional signs are not always provided, where required by 19.2.10.1:

1) The Basement Level (Concourse) has a 12' wide Main Corridor extends east and west the length of the building. There is a fire shutter that divides this corridor at the middle of the building, into two separate fire compartments. Western comparments lacks exit signs that direct the means of egress to an exit. Two pairs of doors near the fire shutter, on the west side of the shutter, lack illuminated exit signs directing the path around the fire shutter back to an exit path to the east (through C051 and C052).

2) Basement Corridor C051 and C052 is a required exit access corridor for the C100 Rehabilitation Services Unit and for the Unit to the west that contains the Islet Lab. The surveyor notes that exit access corridors, suites and horizontal exits are not clearly identified on plan provided by the facility (see K048). The surveyor finds that Corridor C051/C052 lacks an identified send means of egress out of the corridor in accordance with 19.2.5.8. The Vestibule C291 that is north of C051 has two pairs of doors that swing to the south and not in the direction of exit travel (opposite swinging doors required because of item 1 above and item 2).

a) The 1st set of doors (south pair of doors for Vestibule C291) are not identified as fire doors that are part of an existing horizontal exit. An exit sign directing the exit path north is not provided. One of two door leafs on this pair of doors does not swing in the direction of exit travel.

b) The north pair of doors in Vestibule C291 are identified as three hour fire doors. An exit sign directing the exit path north is not provided. They are not identified as an existing horizontal exit (but may be required as such). If this pair of fire doors is not an existing horizontal, one of two door leafs on this pair of doors does not swing in the direction of exit travel.

Based on random observation during the survey walk-through, not all exits are identified in accordance with 7.10.

Findings include:

A. At the Basement, two exit signs are not illuminated in the path to entrance B1CA as required by 7.10..

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. An exit sign was observed, above a door from Second Floor Suite 2C which can be secured against egress, which does not direct occupants toward an exit as required by 7.10.1.1.

B. Exit signs were observed that are not continuously illuminated as required by 7.10.5.2. Locations observed include:

1. Corridor 1016, exit sign at north end.

2. Corridor 1014, exit sign at east end.

A) The surveyors reviewed the Hospital written fire plan. Their plan indicates that they follow the R A C E acronym and the surveyors observed that RACE instructions are posted throughout the Hospital.

1) The Hospital indicates that the current fire alarm system annunciates throughout the entire facility and then staff response throughout the entire facility is expected to follow the RACE acronym. However: This is not clearly indicated in their written fire plan

a) The written plan does not clearly indicate that staff is expected to follow the RACE acronym, throughout the hospitals during fire drills.

b) Portions of the written fire plan have instruction that conflict with the RACE acronym. Item "D," subheading "b" on page 4 of 10 of the written plan indicates that if the fire is not in their area, staff is to "continue normal operations." When and where staff is expected to respond using RACE is not clearly identified.



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Based on random observation during the survey walk-through, staff interview, and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

B. During a series of interviews held throughout the survey walk-through between February 22 and 25, 2010, the provider's staff was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 19.7.1.1. Further, during the survey walk-through, it was determined that existing records of such components were inaccurate for the reasons listed herein. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include, but are not necessarily limited to:

1. Occupancy classifications.

2. Portions of the building covered by an automatic sprinkler system. Surveyor 14290 notes that numerous Electrical Closets within the building are not covered by the automatic sprinkler system; these spaces were not identified as such on provided drawings.

3. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, and building separations. Regarding horizontal exits, Surveyor 14290 notes that each building story is shown on the provided drawings as being divided into several fire comparments. However, the provider's staff was not able to clarify which, if any of the fire barriers separating these fire compartments constituted horizontal exits. The provider's staff was thus not able to demonstrate compliance with:

a. 19.2.6.2.2. with respect to the maximum allowable travel distance to an exit.

b. 7.2.4.3.2. with respect to the protection of window openings within 10'-0" of locations where horizontal exits terminate at outside walls where such outside walls are at an angle of less than 180 degrees.

c. 9.6.2.1(1) and NFPA 72 1999 2-8.2.2., with respect to the provision of manual fire alarm pull stations within 5'-0" of doors in horizontal exits.

4. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, ventilation shafts, and linen and/or refuse chute shafts. Surveyor 14290 notes that not all shafts are indicated in the same manner on the provided drawings.

5. Smoke barrier walls and areas (in square feet) of smoke compartments. Surveyor 14290 notes that no smoke barrier walls are shown on the provided drawings. The provider's staff was thus not able to demonstrate compliance with 19.3.7.1. with respect to:

a. The maximum allowable area for smoke compartments.

b. The maximum allowable travel distance from the most remote point of a smoke compartment to a door in the smoke barrier wall.

6. Exit access corridors and designated corridor walls.

7. The limits and areas (in square feet) of all suites. Surveyor 14290 notes that:

a. Numerous portions of the building appear to constitute suites as defined by 19.2.5., but are not shown on the provided drawings as such (also refer to K-017, K-018, K-038, K-042, and K-072). Portions of the building which appear to constitute suites, but are not so identified include:

1) Fourth Floor:

a) Office Unit including Office 4300.

b) Caesarian Section Unit which includes Passage 4280.

c) The Neonatal Intensive Care Unit, which was identified by the provider's Project Architect, during an interview held on the morning of February 24, 2010 as constituting a single suite excluding the Locker Rooms and NICU 4331.

2) Second Floor:
a) Radiology Suite which includes Passages 2286, 2339, and 2343.

b) Imaging suite which includes Work Area 2477.

c) Cardiac Cath Suite which includes Work Area 2199.

d) Pediatric Heart Unit which includes Office 2105.

e) Office Unit which includes Office Area 2201.

f) Patient Treatment Unit which includes Office Area 2200.

3) First Floor:

a) Administrative Unit which includes Conference Room 1310.

b) Administrative Unit which includes Office Area 1400.

c) Nursing Administration Unit which includes Office Area 1500.

d) Several other possible suite locations on the south side of the building, east of Lobby 1000.

4) Concourse Level Rehabilitation Services Unit.
B. Suites are shown on the provided drawings which either do not constitute suites or do not comply with applicable codes as suites (also refer to K-017, K-018, K-038, K-042, and K-072). Locations observed include:

1) Seventh Floor Intensive Care Unit.

2) Third Floor Surgical Department Suite.

3) First Floor Emergency Department Suite.

8. Hazardous areas and their fire resistance ratings.

9. Locations of any special locking devices.

10. The locations of any special fire protection elements such as fire shutters or window protection.

11. Rolling fire doors or special protection components.

12. Exits.

Based on random observation during the survey walk-through and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During a series of interviews held throughout the survey walk-through on February 25, 2010, the provider's staff was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 21.7.1.1. Further, during the survey walk-through, it was determined that existing records of such components were inaccurate for the reasons listed herein. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include, but are not necessarily limited to:

1. Building construction types.

2. Occupancy classifications.

3. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, and building separations. Regarding horizontal exits, Surveyor 14290 notes that the First and Second Floors are shown on the provided drawings as being divided into at least 2 fire comparments. However, the provider's staff was not able to clarify which, if any of the fire barriers separating these fire compartments constituted horizontal exits. The provider's staff was thus not able to demonstrate compliance with:

a. 21.2.6.2. with respect to the maximum allowable travel distance to an exit.

b. 7.2.4.3.2. with respect to the protection of window openings within 10'-0" of locations where horizontal exits terminate at outside walls where such outside walls are at an angle of less than 180 degrees.

c. 9.6.2.1(1) and NFPA 72 1999 2-8.2.2., with respect to the provision of manual fire alarm pull stations within 5'-0" of doors in horizontal exits.

4. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, ventilation shafts, and linen and/or refuse chute shafts.

5. Smoke barrier walls and areas (in square feet) of smoke compartments. Surveyor 14290 notes that no smoke barrier walls are shown on the provided drawings. The provider's staff was thus not able to demonstrate compliance with 21.3.7.2. with respect to the division of those building stories which constitute ambulatory health care occupancies into at least 2 smoke compartments.

6. Hazardous areas and their fire resistance ratings.

7. Locations of any special locking devices.

8. Exit Passageways. Surveyor notes that Corridor 1012 is shown as an exit passageway serving Exit Stair S-1; see K-033.

9. Exits.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2.

Findings include:

A. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar year 2009, fire drills for the following quarters/shifts were conducted at the similar times listed [all Third Shift (11:00 PM to 7:00 AM):

1. 5:00 AM (1st Quarter) 03/13/09

2. 4:00 AM (2nd Quarter) 06/05/09

3. 4:00 AM (3rd Quarter) 09/18/09

4. 5:00 AM (4th Quarter) 12/31/09

B. The fire drill report did not include any information as to the staff being able to hear the announcements and or alarms.

A) The Hospital has an existing fire alarm system with a staff notification mode and a evacuation mode. The staff notification mode is labeled as a "pre-signal system". However, it is not a pre-signal system as defined by NFPA 72. The staff notification mode is designed to notify hospital personnel of an activation of the fire alarm system throughout the building via an audible chime code alarm and by red visual devices.

There is also a new addressable fire alarm system that has been installed throughout the facility, roughly parallel to the exiting fire alarm system. Although this new system is mostly installed and functional, the installation is incomplete. The new system has not been tested and has not been approved for use. Some supervisory and/or alarm functions may be tied to the new system and not to the existing system.

Specific interim life safety measures have been required for any and all deficiencies relative to either system.

1. The existing fire alarm system is not installed and maintained in accordance with NFPA 101, NFPA 25 and NFPA 72:

a. Fire alarm pull stations on the 9th, 10th
and 11th Floor mechanical spaces do not
function in accordance with NFPA 72.
During testing on 02/24/10, the fire
alarm pull stations on the floors
indicated failed to activate fire alarm
chimes and visual devices on every floor
of the Hospital

b. Fire alarm chimes on multiple floors and
multiple locations are barely audible or
cannot be heard at all.

c. Corridor doors, suite boundary doors,
required fire rated doors with automatic
opening functions are not disabled and
the doors to not close to latch, upon
activation of the fire alarm system.
Locations include but are not limited to:

two pairs of fire doors for 6 West

Corridor door to 3rd Floor PACU (3584)

d. Multiple doors that are part of a required
the means of egress have locking devices
with delayed release. These doors to not
release immediately upon activation of
the fire alarm and sprinkler system in
accordance with 7.2.1.6.1. Example:
4th Floor door to Stair # 3.

2. Basement Level C 900: These is a smoke detector in this space that is mounted four feet below the deck above.



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Based on random observation during the survey, not all the building fire alarm system are installed or tested in accordance with 19.3.4. Findings include:

B. Based on record review and interview, the facility failed to provide complete documentation of smoke detector testing in accordance with LSC Sections 9.6.1.3 and 19.3.4.1 and NFPA 72, 1999 Edition. During record review it was determined that the facilities testing company (Siemens) has not conducted or provided documentation as to when the last Sensitivity Test was conducted. The report will need to indicate the manufacture's range, devices physical location and if the individual detectors "pass" or "failed." The documentation failed to provide a test to confirm that all of the smoke detectors operated within the manufacture's activation range.

C. Fire Protection Company (Cybor), 7/30/09 report item#18, states: "Please note that the pressure switch and air maintenace device on 1st floor south building MRI preaction system has a history of unreliability and should be monitoed closely. If issue persist, we highly recommend making repairs to help maintain system integrity. Inaccurate / unreliable air gauge on south penthouse dry pipe valve. Please note max fire pump discharge psi exceeds rated max psi of some fittings/components. Please note the AMD on the south concours zone#2 is showing signs of unreliability and may require future replacement. Please note the control valves for the 1st floor south loading dock dry valve and the penthouse south dry valve have packings that are near the end of their adjustment and may require repack/replacement in near future." The facility could not produce any plan of action, purchase order, or work order to verify if all issues related to this report have been/or will be corrected.

A) Based upon random observation the surveyors find that sprinklered systems are not installed and maintained in accordance with NFPA 13:

1) Electrical Rooms typically are not sprinklered and instead use an exception under NFPA 13 that requires a two hour fire rated enclosures for each unsprinklered electrical room. A number of electrical rooms do not comply with the exception under NFPA 13:

a) A number of these electrical rooms are
used for storage (strictly prohibited
unless the rooms are sprinklered).

Basement Level Sub Station C905 -
storage in unsprinklered electrical room

Basement Level C904 - storage in
unsprinklered electrical room

Basement Level C904A - storage in
unsprinklered electrical room

Basement Electrical Room C1 has
visqueen on the floor.

b) The two hour enclosure for some rooms
is incomplete. Examples:

i) 9th Floor Electrical Rooms have
pairs of 1 1/2 hour fire doors. These
doors also have a transom panel above
the doors that are only 1/2" to 3/4" thick.
There is no evidence that indicates that
the transom panels constitute either a 1
1/2 hour or a two hour fire barrier in
accordance with NFPA 80 and/or 8.2.3
of NFPA 101.

ii) Basement Electrical Closet C622A
is not sprinklered. The room has a 1 1/2
hour fire doors but the room has no
fire enclosure walls above the ceiling.

iii) Communication Closet (C263) this
triangular shaped room has no sprinkler
protection. The room has not ceiling and
is open to the adjacent ceiling cavities
(which are not sprinklered)

2) Sprinkler heads are not installed in accordance with NFPA 13:

a) 10th Floor: Storage Room P101A,
inside the 10th Floor Elevator Machine
Room.

b) 10th Floor (or possible 9th Floor):
There is a north door from Stair: 4 that
provides access to the Mechanical
Room. Sprinkler protection is not
provided in the Southeast corner of this
space (space includes a Fitter's Cabinet)
or the sprinkler heads above are blocked
by ductwork.

c) Basement - Dietary Walk-in Freezer
# 2 has storage on the center shelves
that are closer than 18" below the
sprinkler heads in this space.

d) Basement - Dietary: Walk-in Unit C420
has a missing access panel high on the
back side of the unit. The Kitchen is
open to the unsprinklered space above
this walk in unit

3) Sprinkler protection (and any fire alarm detection devices) are compromised by missing of ceiling tiles in lay-in ceilings. Locations include but are not limited to:

a) Basement Level

Ë446 - Linen Holding Room

Data Room ( with raised floor) inside
C268

Room C268 has sprinkler heads with
"hats" the heads are installed too far
below the ceiling above.

C250

Janitor's Closet (w/ Fire Zone 1-1-6
Room C 3) on door

4) The Basement Level Islet Lab is protected with a pre-action sprinkler system. The entrance vestibule and the viewing space both appear to be protected by this pre-action system but these two spaces lack detection devices that will charge the pre-action system. A system narrative for how this pre-action system functions was not available.

5) Basement Level Data Center C250 is protected by a pre-action sprinkler system. The room was observed with multiple detection devices including three devices side by side. A narrative for the function of these devices and how this pre-action system functions was not available.



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

B. Materials were observed being stored less than 18" below sprinkler heads as prohibited by NFPA 13 1999 5.6.6. Locations observed include 3rd floor, Tissue Processing -Gross (3114B) Sprinkler located above a work station hood and is not provided with 18" clearance.

C. Rooms or spaces were observed at which ceiling tiles or surfaces were observed to be missing or damaged compromising sprinkler coverage as prohibited by NFPA 13, 1999 5-6.4.1.1. Locations observed include:

1. 7th floor, Medication Room (7544E) the ceiling tiles were not seated into the frame due to low voltage wiring obstruction.

2. 7th floor, Janitors Closet (726W) the plaster ceiling was observed to contain a penetration that was not sealed.

3. 7th floor, Soiled holding - Biohazards (7106W) ceiling tiles are not setting into the frame, breaching the ceiling plane to cavity above.

4. 3rd floor, Cytology Screening Room (3135 A-C) Several ceiling tiles were damaged, including holes and missing corners.

5. 1st floor, Triage, ceiling tiles were missing.

6. 1st floor Main Entrance Lobby, the enclosed vestibule / airlock was not provided with sprinkler protection. This vestibule is like a box sitting in the lobby area, and is not constructed to the ceiling deck above. The space above the vestibule was not provided with sprinkler protection either.

7. 1st floor, Storage (1133) off of main lobby, is not provided with sprinkler coverage.

D. The exterior canopy for ER, under which ambulances were parked was observed to lack sprinkler heads required by NFPA 13, 1999 5-13.8.2.

E. Sprinkler heads were observed that are are not being maintained in accordance with NFPA 25, 1998. Conditions observed include:

1. 7th floor Charting Room (75310) contained a sprinkler head recessed into the ceiling cavity, and not extend past the ceiling tile plane.

2. 7th floor Stair #2, fireproofing from the roof/deck is visible on the sprinkler head.

F. Sprinklers were not installed in the following locations as required for a fully sprinkled facility.

1. 7th floor, all patient room closets. The sprinklers located within the patient room were not located to include accurate coverage of the patient room closets.

2. 7th floor, Oxygen Storage (751EA) at the nursing station is a 2 hour rated enclosure based on the drawings, but the room did not contain sprinkler protection.

3. 5th floor, all patient sleeping room ardrobes. The sprinklers located within the patient room did not appear to be located to include coverage of the patient room closets.


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G. Patient Sleeping Room Wardrobes were observed that are not covered by the automatic sprinkler system as required by NFPA 13 1999 5-1.1(1). Locations observed include:

1. Eighth Floor, Patient Sleeping Rooms west of Column Line 8.

2. Sixth Floor, Patient Sleeping Rooms east of Column Line 12.

H. Ceiling tiles were observed to be missing in Eighth Floor Storage Room 870E, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1.

I. Electrical Closet 665WA was observed to be open to the ceiling cavity, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1.

J. Sprinkler heads were observed that are missing escutcheon plates as prohibited by NFPA 25 1998 2-4.1.8. Locations observed include:

1. Eighth Floor Medication Room 843E.

2. Second Floor Corridor 2310, near Bridge to Outpatient Care Center.


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Based on direct observation the surveyor finds the facility failed to provide:

K. Automatic sprinkler protection for the high voltage switchgear located outside the protected electrical switchgear room enclosures. Sprinkler heads have been removed from over and around the area where high voltage switchgear is installed within the air handling equipment room. Combustible storage is located within the footprint where the sprinkler protection has been removed. The installation does not meet the exceptions listed in NFPA 13, 1999, 5-13.11 for elimination of sprinkler protection.

A) Based upon random observation, the surveyor finds that manual fire extinguishers are not maintained in accordance with NFPA 10:

1) The provider documents monthly visual inspections with a written procedure that requires a visual inspection and bar code scan to document the inspection. Most fire extinguishers have a unique UIC bar code on each device. Some of the fire extinguishers observed did not have an individual bar code. The provider was not able to demonstrate how the fire extinguishers that lacked individual bar codes were inspected and documented.

A) Based upon random observation and document review, the surveyors find that fire dampers and/or fire/smoke dampers are not installed and maintained in accordance with NFPA 90A.

1) According to the provider and based upon documentation, fire dampers were tested, cleaned and maintained in 2007 for the 949 Building (Main Hospital). The documentation identifies dampers that could not be accessed, dampers that need cleaning or replacement, dampers that are broken etc.

The provider had no documentation that indicates when and how the above items have been corrected.



12798


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

Findings include:

B. 3rd floor surgery electrical closet (3520) defined as a 2 hour rated room on the drawings. This unsprinkled closet contained a duct penetration that was not provided with a fire damper as required for a 2 hour rated enclosure.



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C. A series of perimeter ventilation shafts were observed which connect the Eighth through Fourth Floors between pairs of Patient Sleeping Rooms (as well as other perimeter rooms) in the Hospital. Based on document review, it was determined that there appear to be 42 such ventilation shafts, all serving below-window induction units. Penetrations of the ventilation shafts by ductwork (typically 1 such penetration for each pair of rooms on each building story) were observed to lack fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.1.1.

A) Based upon direct observation and review of documentation for the past 14 months, the surveyor finds that kitchen hood suppression systems are not installed and/or maintained in accordance with NFPA 17A and NFPA 96:

The facility has three hood suppression systems that are required. Two are in the 1st Floor Cafeteria Serving area and the 3rd is in the Basement Dietary Department main cooking line. All system are ANSUL wet chemical systems. The 1st Floor hoods have removable grease filters while the Basement has an engineered grease extraction system

1) The 1st Floor suppression systems each has a fryer and a flat grill under the hoods (they have the same equipment. The hoods, the ANSUL pull station, the ANSUL "box" with the suppression tank and the documentation all lack a unique identifier or reference for each hood. While some of this is apparent, some of it is not apparent and should be clearly identified in accordance with the above referenced standards.

2) The testing documentation for the last two semi-annual inspections:

a) does not identify the type of equipment and the manufacturer of the equipment protected under each hood.

b) The forms used by the outside contractor to document semi-annual inspection is very detailed and is comprehensive. However, there are conflicts or blank areas to be checked that are not. Some of the items marked "NA" need further written explanation. Item # 47 on the form indicates that shut trip breakers are not required, yet other parts of the form indicate that shut trip breakers are installed and were tested.

c) Line # 49 on the forms list a location where the contractor can identify where shut trip breakers are located; a location is not identified.

d) The semi-annual testing documentation of 9/21/09 for a first floor kitchen hood indicated that there hole in the hood that needs to be patched. The provider was not able to indicate when and how this item was corrected.

e) The documentation for the Basement hood suppression system dated 9/21/09 indicates that the suppression system does not comply with the manufacturer's recommendation but does not indicate what the issues were. It also indicates that the suppression system does not comply with U L 300.

The surveyor finds that the system was modified on 1/30/10 to comply with U L 300; however full documentation and retesting certification of the entire system was not available on site.

3) All hood suppression system have electrically fueled appliances that must be disconnected from the fuel source upon activation of each system. Shut trip breakers are installed and tested for each system. Each system has an electrical panel with circuits that identify the appliances on that panel. Below each panel is a main shunt-trip device that disconnects all or part of the panel directly above it.

a) The shunt-trip device below each panel is not clearly identified and also does not clearly identify what is disconnected (entire panel above, individual circuits, etc).

b) The electrical panel above each shunt-trip device does not accurately identify the circuit and equipment supplied from the panel. Some of the equipment identified on the panels are no longer installed.



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Based on direct observation, the surveyor finds:

B. The installation of the kitchen grease duct and utility fans within the 9th floor mechanical penthouse are in non-compliance with NFPA 96, 1998.

1. The connections for the kitchen hood exhaust ducts to the utility fan sets are flexible connections prohibited by NFPA 96, 1998, 5-1.3.

2. The shaft enclosure for the grease ducts from the basement through the floor of the 9th floor mechanical penthouse is not vented to the exterior of the building. (NFPA 96, 4-7.1)

3. The grease duct shaft enclosure within the mechanical penthouse is not continuous to the exterior of the building. The grease ducts penetrate the top of the shaft unprotected to the exterior of the building as prohibited by NFPA 96, 4-7.1.

Based on random observation during the survey walk-through and staff interview, 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. Carts and equipment 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. Eighth Floor:

a. Visitors' Elevator Lobby, gurney and wheelchair.

b. Corridor 8143, 2 wheelchairs.
2. Sixth Floor:
a. Corridor 6132, 2 work stations on wheels.

b. Corridor 6135, 2 work stations on wheels.

c. Corridor 6139, 2 work stations on wheels and 1 wheeled equipment pole.
d. Isolation Vestibule 682E, work table obstructs sole access from Patient Isolation Room.

3. Fourth Floor:

a. Corridor 4052, portable x-ray machine.

b. Corridor 4127, wheeled equipment pole.

c. Corridor serving Office 4300, audio-visual equipment and furniture (also refrer to K-048).

d. During an interview held at the site on the morning of February 23, 2010, the Caesarian Section Unit Nurse Manager stated that gurneys are stored in Corridor 4280, as prohibited by 19.2.3.3. and 7.1.10.2.1., while cases are underway (also refer to K-048).

4. Second Floor (also refer to K-048):

a. Radiology Unit Corridors 2286, 2339, and 2343, work areas and equipment.

b. Imaging Unit Corridor 2477, work stations and equipment.

c. Cardiac Cath Unit Corridor 2199, work stations and equipment.

d. GI Unit Corridor 2309, equipment.

e. Office Unit Corridor 2201, work stations.

f. Treatment Unit Corridor 2200, work stations.

Based on random observation during the survey walk-through, not all Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended. 19.7.5.5.

Findings include:

A. Floor 7, corridor wheelchair storage niche (759W) contained a recycle cart exceeding the 32 gallon capacity.

B. Floor 5, corridor niche (522E) contains two carts, exceeding the 32 gallon capacity and blocking access to electrical panel 5L3C.



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C. A trash receptacle with a capacity in excess of 32 gallons was observed being stored in Fourth Floor Corridor Alcove 459W as prohibited by 19.7.5.5.

A) From observation, the surveyor finds that oxygen is stored in the Basement Level I V Fluids Storage Room (C985). The oxygen tanks were stored closer than 5'-0" to combustible and do not comply with NFPA 99 - 1999.



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

Findings include:

B. 5th floor, clean holding room (567W), contains 7 oxygen tanks that were not provided with the 5'-0" clearance from combustibles as prohibited by NFPA 99, 8-3.1.11.2.c.2 for sprinkled portions of the facility.


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C. Medical gas tanks were observed being stored, in Eighth Floor Storage Room 830E, that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2).

(Information 02/23/2010): Based upon observation and personnel interviews, the surveyors find: The UIC West Plant is made up of two buildings; both are located on the south side of Taylor Street, directly across the street from the Hospital:

1) The 952 Building which houses four, diesel fired emergency generators.

2) The 921 Building which includes a very large and complex electrical distribution system for the UIC West Campus and.

a) It houses three, high pressure, gas fired,
co-generation power, turbine generators
that are designed to provide normal
power to the UIC West Campus and
UICMC. The co-gen systems produce
steam as a by product that is used as a
source of steam for the UIC
West Campus and the UICMC (and
Rush University Medical Center).

b) The 921 Building also houses multiple
peak load generators that are designed to
supplement normal power.

c) The 921 Building houses multiple
chillers

d) The 921 Building houses 7 large boilers
that are designed to provide steam for
heat, humification and sterilization for
the UIC West Campus and the UICMC
(and Rush University Medical Center).
Of the seven boilers only Boiler # 5 and
6 were operational. (Boilers 1 through 4
have been decommissioned. Boiler 7
is non-operational and is scheduled
for replacement.

A) (Modified 02/22/10): The Hospital does not comply with NFPA 99-1999. During a complaint investigation on December 9, 2009, the surveyors observed that the Hospital lost ability to produce heat, hot water and humidification. Further, the hospital lost the ability to produce steam for sterilization. This occurred on three separate dates, 12/04/09, 12/07/09 and 12/08/09.

1) The surveyors note that these events took place because the hospital lost steam pressure from the UIC West Plant that is located just south of the Hospital. The West Plant has two systems that produce steam. Both systems failed due an internal, normal power, distribution failure. Neither system is backed up by an emergency power that is installed and/or maintained in accordance with NFPA 70, NFPA 99 and NFPA 110. The lack of emergency power for the system(s) that provides heat to the Hospital's operating rooms, delivery rooms, recovery areas, intensive care areas, nurseries, etc. does not comply with NFPA 99 - 1999, 3-4.2.2.3 (e) 1).

a) The existing boilers are not connected to
an emergency power source.

b) The co-gen turbine generators are
designed only to run and provide steam
when normal power is available. This
system is not designed to function under
emergency power or an alternative
power source when normal power is
interrupted.
.
2) Further, the surveyors note that any interruption of normal power in the West Plant shuts down all of the steam producing equipment (new system and old system) in the plant. A power failure occurred on the evening of Monday, December 7, 2009. Normal electrical power was interrupted to the UIC West Campus, to UIC Medicare Center and to the steam producing equipment in the West Plant. This arrangement does not comply with 3-4.2.2.3 (e) 1) (NFPA 99 - 1999).

3) Deleted 02/25/10

4) (02/23/10): A temporary, 1 Megawatt, emergency power system (mobile generators) is kept on site at the West Plant as a back up system. This back up system is not currently connected to the building and is not currently being used to provide normal or emergency power to to the West Plant. It is available to provide power to the existing old boilers (Boiler # 5 and 6) if normal power fails, as an interim measure.



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By direct observation the surveyor finds:

A. The generator for supply of emergency power to the fire pump located in the 920 building is not provide with a remote manual emergency stop station. (NFPA 110, 1999, 3-5.5.6)

B. The four emergency generators, located in the 952 building, serving the essential electrical system for the Medical Center, are not provided with remote alarm annunciators at a constantly attended work station as required by NFPA 99, 1999, 3-4.1.1.15 (b).

Based on general observations it was observed in the Basement mechanical room that indirect waste piping from the "clean drain" was not provided with an air gap at the floor drain. As required by the Illinois Plumbing Code 890.1040.

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. 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.

Surveyor 07113:

1. The provider lacks interim life safety measures for the deficincies observed (refer to K-051).

B. Basement Level Carpenter Shop: Access was not provided. Surveyor could not confirm one hour fire rated enclosure for a high hazard area and sprinkler head spacing for high hazard could not be confirmed.

C. CFR 482.41(a) (A701 - Maintenance of Physical Plant): The condition of the physical plant and the overall hospital environement must be developed and maintained in such a manner that the safety and well-being of patients are assured. (this item may not be corrected until A701 is corrected - form 2576b required by surveyor).


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By direct observation the surveyor finds:

The facility failed to provide a means for providing fuel for heating should the utility supplied fuel become interrupted as required by:

A703 CFR 482.41(a)(2) There must be facilities for emergency gas and water supply.

(The hospital must have a system to provide emergency gas and water as needed to provide care to inpatients and other persons who may come to the hospital in need of care. This includes making arrangements with local utility companies and others for the provision of emergency sources of water and gas. The hospital should consider nationally accepted references or calculations made by qualified staff when determining the need for at least water and gas. For example, one source for information on water is the Federal Emergency Management Agency (FEMA).

(Emergency gas includes fuels such as propane, natural gas, fuel oil, liquefied natural gas, as well as any gases the hospital uses in the care of patients such as oxygen, nitrogen, nitrous oxide, etc.)

(The hospital should have a plan to protect these limited emergency supplies, and have a plan for prioritizing their use until adequate supplies are available. The plan should also address the event of a disruption in supply (e.g., disruption to the entire surrounding community).

A) From random observation, the surveyors find that electrical installations and materials do not comply with NFPA 70:

1) Access to electrical panels or switchgear was blocked:

a) Basement Storage Room C508: Storage
in front of switchgear.

2) Electrical extensions cords are used for permanent power

a) Basement Level Midnight Pharmacy
Hood - yellow cord on floor

3) Basement Level C900:

a. There is a black cable that is strapped to
the electrical conduit (overhead) in this
area. The provider did not know what
the black cable was or how it complies
with NFPA 70.

b. There is an electrical panel in the
Northwest corner of the electrical space.
The panel lacks identification. Some
circuits lack identification and access to
the panel is blocked by storage. and by a
table with a vise.

c. There are multiple electrical extension
cords strapped to electrical conduit in
this area.



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Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

B. 7th floor, Staff Break Room (770E) contains electrical panel 7LPT-1. The directory numbering and referencing does not match the actual numbering on the circuit breakers in use.

C. 3rd floor, Surgery (OR #12), the surface mounted wire chase is missing a cover or protective plate.



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D. Critical care patient beds were observed at which electrical receptacles served by the building emergency electrical system are not labeled as to panel and circuit number as required by NFPA 70 1999 517-19(a). Locations observed include (all Sixth Floor):

1. Patient Sleeping Rooms within designated Intensive Care Suite.

2. Patient Sleeping Rooms in Intensive Care Unit north of Suite.

A) Based upon random observation and personnel interview, the surveyors find all elevators (ten of ten) lack automatic recall (floor and alternate floor) from activation of the Old Existing Fire Alarm System (see also K051) in accordance with ANSI A17.3.

The surveyor notes that automatic recall may be functional from the new addressable Fire Alarm System that is being installed. However, this new system is currently incomplete and not tested. Elevator recall functions are currently by-passed on this new system.

This citation does not apply to dumbwaiter systems or to freight elevators.