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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) Corrected 11/08/11






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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:

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

Updated 03/05/12: A portion of the E D East Foyer (with the revolving door) has a beam that has missing fire proofing. The beam runs east to west in the middle of the foyer and is mostly concealed by insulation above the ceiling. Confirm all steel in this area. What supports the beam? Is it fire proofed?

Revise PoC and resubmit.





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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. Modified 11/08/11: 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.
Second Floor::

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?

It is not clear how the above area complies with 19.3.6.1 or the rules for suites. If this area is not a suite, it lacks smoke detection throughout all areas that are open to the corridor. However, it appears to be a suite. K017 will clear when the PoC identifies this space as a suite. See also K042

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.

11/08/11 - the surveyor observed that provider is not following the PoC and written policy for the above area. Pallets supplies were observed in the corridor, obstructing a portion of the 8'-0" width. An unused wood pallet was left in the corridor and a significant number of wheeled waste cards for shredded paper were found in this corridor, obstructing the corridor down to about 5'-0" in width.

2) Corrected 06/03/11

3) Corrected 03/05/12





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B. Corrected 03/05/12

A) (New 11/08/11): Treatment Unit Work Areas as part of Corridor 2200. This area appears to be a suite and is identified on Life Safety Plans as a Suite. The adjacent suite is vacant and under construction.

1) The suite does not appear to have two remote exit paths from the suite. The corridor door to the south does not swing in the direction of exit travel.

2) The path to the northwest requires travel into an adjacent suite (permitted) to get to a stair. The foyer in front of the stair is used as a storage holding space (not permitted - does not comply with 19.3.2.1.)

3) A door to the adjacent suite was wedged open.

4) The file storage room at the north end of this suite that is a hazardous area. The door closer on this door to this room has been removed; the door no longer complies with 19.3.2.1.





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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. (Modified 11/08/11) 3rd floor, the designated OR Suites exceed 10,000 square feet as prohibited by 19.2.5.7. Based on the PoC and Life Safety Plans, the suite has broken up into multiple smaller O R Suites.

1. The East Suite still exceeds 10,000 Square Feet (Suite 3-2 - 11,220 SF)

2. Deleted 03/05/12

3. The North Suite(Suite 3-1) is 11,030 square feet in area (exceeds 10,000 sf and does not comply with 19.2.5.7).

a. 03/05/12: The surveyor also notes that the exit access corridor to the south has an exit sign that directs the exit path from the corridor north into the suite.

C. (Modified 11/08/11) The 1st floor, the designated Emergency Department Suite is identified as 14,398 square feet in area and exceeds the 10,000 SF limit as prohibited by 19.2.5.7.

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

1) Corrected 11/07/11

2) Sprinkler heads are not installed in accordance with NFPA 13:
a) Corrected 11/07/11
b) Corrected 10/05/10
c) Corrected 11/07/11
d) Corrected 11/07/11
e) Corrected 03/05/12


f) (New 11/08/11): Sprinkler closet 536W
lacks sprinkler protection

The above item was not corrected -
revise and resubmit

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: E446 - Linen Holding
Room





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C. Corrected 03/05/12
E. Corrected 11/07/11.
F. Corrected 11/07/11



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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. Corrected 11/07/11
2. Corrected 06/02/11

H. Corrected 11/07/11
I. Corrected 11/07/11
J. Corrected 06/02/11




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K. Corrected 03/05/12

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.

11/08/11 - based upon a review of documentation the surveyor finds that all dampers are not documented. 3-FD1 and 3-FS2 are identified as documented on the 4th Floor but no reference to these damper numbers are identified on the 4th Floor. Damper identification is require by device and not but location. Two additional dampers 5-FD35 and 7-FD29 are identified as not tested.

b. Corrected 11/07/11

B) Corrected 03/05/12






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B. Corrected 03/05/12




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C. Deleted per compliance with earlier edition of NFPA 90A - 11/07/11

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) Deleted 03/05/12

a) Corrected 11/08/11

b) Deleted 03/05/12

c) Deleted 03/05/12.

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) (Modified 03/05/12) The 1st Floor shunt-trip devices located directly below each panel does not clearly identify what is disconnected by the shunt trip device(entire panel above, individual circuits, etc ?). The provider does not know if the enitre panel shuts down from the shunt trip or whether specfic circuits shut off.

b) The electrical panels above each shunt-trip device (1st Floor Kitchen Panels) do not accurately identify the circuit and equipment supplied from the panel. Some of the equipment identified on the panels are no longer installed. Two sets of numbers are used for circuits that do not match. Schedules on panels marked in black marker and panel schedules do not match.

03/05/12: The above item was not corrected.

B) (New 11/08/11): 1st Floor Servery - a large cart was left in front of Electrical Panel 1LK6' 3'-0" of clear space in front of the panel was not provided (note: this deficiency includes the cart but not the cook).

C) Lower Level Kitchen Main Cooking Line: The four bank fryer lacks 16" of clear from the grill to the left of the fryer in accordance with NFPA 17A.



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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. Corrected 03/05/12

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)

03/05/12: The PoC does not include
how the above item was corrected.

3. Corrected 03/05/12

A) Corrected 03/05/12

B) Corrected 03/05/12

C) (New 11/07/11): The 3rd Floor exit access corridor in front of the Suite that contains O R, 1, 2 and 3 was obstructed by multiple carts including a very large Endo Cabinet on wheels





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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. Corrected 11/07/11

2. Corrected 03/05/12

3. 5th Floor (New 11/07/11)

a. Corrected 03/05/12

b. The exit access corridor near
580W - 599W was obstructed by
a chair, IV stands, a scale and
soiled linen hampers .

c. Corrected 03/05/12

4. Corrected 06/02/11.

5. Second Floor

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, 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. Deleted 03/05/12 - Note that above item will remain until all deficiencies are corrected.

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

D. Corrected 03/05/12




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The citation below is cited for the lack of an alternate fuel source and not for the lack of an emergency water plan.

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:

The information below is CMS requirements for the above citation.

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). .