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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) Corrected 10/05/10

2) Basement Level

a) Corrected 10/05/10
b) Corrected 10/05/10

c) There is a pair of fire doors next to
Room C288. Fire proofing is missing
from a beam above the ceiling, 14' west
of the doors.

6/07/11: Access is limited; the steel
beam appears to have exposed brown
colored primer coat (or exposed rusted
steel) that appears to be
exposed unprotected steel rather than
completely fire-proofed steel.






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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. Corrected 10/05/10

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. Corrected 06/02/11

A) Corrected 06/03/11



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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. Corrected 06/03/11
2. Corrected 06/03/11
3. Corrected 06/03/11
4. Corrected 06/03/11

5. Treatment Unit Work Areas as part of Corridor 2200. The PoC for this item does not appear to be accurate; the corridor in question appears to serve patient treatment rooms. How does the corridor comply with the above?

C. Corrected 06/03/11

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 not connected). 06/02/11 the above item was not corrected in accordance with the last submitted PoC.

2) Corrected 06/03/11






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B. Corrected 06/02/11
C. Corrected 06/02/11

A) (New 06/03/11) Based on random observation, the surveyor finds that fire doors, smoke doors and/or fire shutters are not tied to local smoke detection and/or do not close upon activation of smoke detections in accordance with 19.2.2.2.6:

1) The Concourse Level Pharmacy Department has a fire shutter that lacks smoke detection within five feet of the shutter on the ceiling above, on both sides of the shutter.

2) The pair of fire doors to the Concourse Level Prosthetics Lab lacks positive latching and self closing hardware on the inactive leaf. The fire doors lacks smoke detection within five feet of each side of the doors to release the auto open/auto hold open functions on these doors.

3) The 1st Floor Emergency Department fire shutter - based upon the information available on plans, this location does not appear to be part of any corridor, smoke barrier or fire barrier and is therefore not deficient - 6/03/11.

4) Blood Bank Lab 3150 is designated with a one hour fire rated enclosure; based upon testing on 6/03/11, the fire shutter did not close completely.

5) Room 602E (Respiratory) has a fire shutter in a designated fire barrier. The fire shutter lacks smoke detection within five feet of the opening.




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A. Corrected 06/02/11

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
prohibited by 39.3.2.1. and 8.4.1.1.

06/07/11: The above citation will be
observed over multiple on site visits,
to observe consistent compliance,
before the tag will be cleared

2) Corrected 06/03/11



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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. Corrected 06/02/11

2. Fourth Floor Clean Storage Room 4261 -
the item was correcged 06/02/11,
however the door was wedged open

3. Corrected 06/03/11

A) Corrected 06/03/11




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B. Corrected 06/02/11
C. Corrected 06/02/11



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D. Corrected 06/03/11

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.

The surveyor observed that the three ducts referenced were not found in the Concourse Level of Stair # 1. The above item will be cleared when the surveyor determines that this condition does not apply to another exit stair.

A. Corrected 06/02/11



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B. (Modified 06/03/11) Six of seven required exit stairs do not comply with 7.2.1.5.2. exception # 1. Surveyors note: 19.2.2.8 cannot be used under exception # 2 except on a stair by stair and floor by floor basis. 19.2.2.8 cannot be used in this facility to lock ever door in a stair against re-entry except under limited conditions that are identified under exception # 1. Further, signage was was not found within the exit stairs which clarifies to building occupants on which levels re-entry is not permitted and on which levels re-entry is permitted. This condition was observed at all Exit Stair as identified below (does not apply to Stair # 4 which has no locks against re-entry).

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 in accordance with 7.2.2.5.4. Such signage shall be visible within the stair enclosure whether the stair door is open or closed. Locations observed include:

1. Corrected 06/03/11
2. Corrected 06/03/11
3. Corrected 06/03/11

4. Exit Stair 4.

5. Corrected 06/03/11
6. Corrected 06/03/11
7. Corrected 06/03/11

06/03/11: Stair # 4 was not cleared becuase the terminus was not properly identified; the stair provides roof access but the stair identificatoin signage does not indicate such.

D. Corrected 06/03/11

A) Corrected 06/03/11



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B. Corrected 06/03/11


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C. Deleted 06/07/11.

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. Modified 06/02/11: The padlock for the accordion door serving Eighth Floor Storage Alcove 886EB does not comply with 7.2.1.5. (the locking device does not allow egress from within the space with the lock engaged). 19.2.2.2.5 may not be used for this locations because the surveyor observed that all staff observed working in the room and/or on the floor did not carry a key to the padlock and the authority having jurisdiction finds that use of 19.2.2.2.5 does not permit the use of padlocks.

A) Corrected 06/03/11



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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.

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) Deleted 6/03/11 (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) Corrected 06/02/11



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B. Corrected 06/02/11



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C. Corrected 06/02/11
D. Corrected 06/02/11

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) Corrected 06/03/11

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.

A) Corrected 6/03/11


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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. Deleted 06/02/11
2. Deleted 06/02/11
3. Corrected 06/03/11
4. Corrected 06/02/11
5. Corrected 06/02/11
6. Corrected 06/02/11

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.

1) Corrected 06/03/11

2) Second Floor: 6/03/11: the areas refernced below are not located within the suites identified in the POC.
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. 6/03/11
this unit appears to have patient
treatment rooms within; the PoC
does not appear to be accurate.

e) Office Unit which includes
Office Area 2201.6/03/11 - this unit appears to have patient
treatment rooms within; the PoC
does not appear to be accurate.


f) Patient Treatment Unit which
includes Office Area 2200.
6/03/11 - this unit appears to
have patient treatment rooms
within; the PoC does not appear
to be accurate.


3) Corrected 06/03/11
4) Corrected 06/03/11
b. Suites are shown on the provided
drawings which either do not constitute
suites or do not comply with applicable
codes as suites (also referK-042).
Locations observed include:

1) Corrected 06/02/11

2) Third Floor Surgical
Department Suite.

3) First Floor Emergency
Department Suite.

8. Corrected 06/02/11

9. Locations of any special locking devices.

10. Deleted 06/03/11
11. Deleted 06/03/11.
12. Corrected 06/02/11

C) (Unresolved 06/03/11): The plan provided for this survey continue to identify corridors inside designated suites. This creates a conflict between the rules for exit access corridors and the rules for suites. In such cases the rules for corridors will be suited and some of the suites will not comply.

A) Corrected 06/03/11

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

a. Corrected 06/03/11
b. Corrected 06/03/11
c. Corrected 06/03/11
Corrected 06/03/11
Corrected 06/03/11
d. Corrected 06/03/11

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

3) The surveyor finds that supervisory and troubles signals are monitored by the fire alarm but not in accordance with NFPA 13 and NFPA 72:

a) The main fire alarm panel on the 1st
Floor (near the main entrance) receives
multiple trouble and alarm conditions
but this space is not constantly attended.

b) The security office in the Emergency
Department receives multiple trouble
and alarm conditions and is constantly
attended. There are no written
procedures in place for this security
office on how to deal with trouble and
supervisor alarm conditions.

c) The U of I Police receive trouble or
alarm signals but only one; they are not
able to receive multiple signals.




12798


B. Corrected 06/03/11

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) Corrected 10/05/10

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

i) 9th Floor Electrical Rooms -
Corrected 10/05/10

ii) Basement Electrical Closet C622A
Corrected 10/05/10

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,
(or P1004A?)
inside the 10th Floor Elevator Machine
Room.

b) Corrected 10/05/10

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 - not corrected 06/03/11

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

Correction of the above item could
not be confirmed. The ceiling is an
open grid and the area above is
painted black. The surveyor observed
on 06/03/11 that some sprinkler heads
were mounted too far below the deck
above and still had "hats". How was
this item corrected?

Corrected 10/05/10
Corrected 10/05/10

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.

6) (New 06/02/11) Room 741WA: The room is sprinklered but has no ceiling. The room is open to the adjacent ceiling cavity. The room is not define by walls; alternately, the adjacent ceiling cavity is not sprinkled.




12798

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. Corrected 06/02/11

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. Corrected 06/02/11
2. Corrected 06/02/11
3. Corrected 06/02/11
4. Corrected 06/02/11
5. Corrected 10/05/10
6. Corrected 10/05/10

7. 1st floor, Storage (1133) off of main
lobby. On 6/03/11, the surveyor
observed that the sprinkler head was
obstructed by storage closer than 18"
below the head.

D. Corrected 10/05/10

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

1. Corrected 06/02/11

2. Modified 06/02/11: 7th floor Stair #2, a
wireless device is taped to the sprinkler
pipe in the stair.

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

1. Corrected 06/02/11
2. Corrected 06/02/11

3. 5th floor, all patient sleeping room
wardrobes. 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. Corrected 06/02/11

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. Corrected 06/02/11




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K. Modified 06/02/11: The low sprinkler head installed in front of Panel MCC, P-3A - ATS-7 is not installed in accordance with NFPA 13.

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

6/03/11: The fire damper was installed; however the room was being used for combustible storage (which is not permitted by NFPA 13 in an unsprinklered electrical closet).



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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) Modified 06/03/11: Based upon documentation of the most recent semi- annual inspection, the surveyor finds that kitchen hood suppression systems are not installed and/or maintained in accordance with NFPA 17A and NFPA 96:

Corrected 06/03/11

1) Deleted 06/03/11

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

a) 6/03/11: still does not identify the type of equipment and the manufacturer of the equipment protected under each hood for three of three hood systems.

b) The forms used by the outside contractor to document semi-annual inspection is very detailed and is comprehensive. However, 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.

6/03/11: The above item was not corrected.

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 for all three systems.

d) Deleted 06/03/11

e) Corrected 06/03/11

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).

6/03/11: The above item was not corrected

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.

6/03/11: The above item was not corrected for the 1st Floor appliances.



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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.

A) (New 06/02/11): 7 West (ICU) is not a suite. On 06/02/11, the surveyor observed that the corridors in this unit were obstructed by computers on wheels, chairs at these computers and by multiple isolation carts.

B) (New 06/03/11): The 3rd Floor North corridors (3210, 3217 and 3332) were obstructed by beds. carts and equipment. Interim measures were not found for this condition.




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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. - 06/02/11: two gurneys
and equpment obstructed the
corridor in front of Room 8107W

b. Corrected 06/02/11
2. Sixth Floor:
a. Corrected 06/02/11

b. Corridor 6135 - 06/02/11 - corridor
had multiple obstructions including
a scale in front of the drinking
fountain.

c. Corrected 06/02/11
d. Corrected 06/02/11
3. Fourth Floor:

a. Corrected 06/02/11.
b. Corrected 06/02/11.
c. Deleted 06/02/11
d. Deleted 06/02/11

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.

A) Corrected 06/02/11
1) Corrected 06/02/11

a) Modified 06/02/11: As a permanent source of emergency
power Genset # 5 is deficient:

i) Corrected 06/02/11
ii) Corrected 06/02/11
iii) Corrected 06/02/11

iv) The Genset # 5 lacks remote monitoring
[remote alarm annunciators at a
constantly attended work station as
required by NFPA 99, 1999, 3-4.1.1.15
(b)].

Modified 06/02/11: The remote
monitoring of Genset # 5 has a constant
alarm point that indicates a "low coolant"
even when the generator is not
running. The provider is not able to
detect an actual low coolant condition with
this ongoing problem.

v) Corrected 06/02/11

b) Deleted 06/02/11
2) Corrected 06/02/11
3) Deleted 02/25/10
4) Corrected 06/02/11
5) Corrected 06/02/11





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A. Corrected 06/02/11
B. Corrected 06/02/11
C) Corrected 06/02/11

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 all deficiencies observed.

B. (Revised 06/03/11): 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 moderate hazard could not be confirmed.

C. Corrected 06/03/11


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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) Corrected 10/05/10

b) (NEW 10/05/10): a large cart was
parked in front of the doors to several
electrical closets in the West Corridor of
the Concourse Level, in spite of the
striped floor and signs indicating no
storage. The provider lacks adequate
means to prevent re-occurrence (near
C952)

c) (NEW 10/05/10): Concourse Level
Mechanical Room C906: Storage blocks
access to electrical panels and
switchgear. 3'-0" minimum clearances
are not maintained in accordance with NFPA 70. Additionally, combustible
storage was observed against electical
panels, transformers or equipement.

2) Electrical extensions cords are used for permanent power

a) Corrected 10/05/10

b) 1st Floor Servery - orange cord,
under baseboard heat, to beverage
cooler

3) Corrected 10/05/10

4) (New 06/02/11): The Electrical Panel (3-LAB-4) in Lab 3110 has a counter top with equipment on the counter that obstructs access to the panel. An adjacent table with equipment on the table and a cabinet under the table also blocks access to the panel. A 3'-0" clear space is not provided.






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B. Corrected 06/02/11

C. Corrected 10/05/10



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D. Corrected 06/02/11

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 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.

Modified 06/03/11: The provider has a certificate that indicates that elevator recall complies with the City of Chicago's requirements. The surveyor was not able to confirm compliance with ANSI A17.3. All elevators in the building are tied to the same recall; it is not possible to recall any elevator without recalling all of them. The provider only allows testing at 4:00AM.

Compliance could not be confirmed from testing; the provider lacks specific documentation that clearly indicates that each elevator:

1. Recalls to the designated primary floors for recall, upon activation of smoke detection devices that programed to recall the elevators.

2. Recalls to the designated primary floors for recall, upon activation of smoke detection devices in elevator machine rooms.

3. Recalls to the designated alternate floors for recall, upon activation of smoke detection devices on the primary recall floor.