HospitalInspections.org

Based on observation, on March 14, 2012 at approximately 7:00am onward, there is no tenant separation barrier of a minimum one hour fire resistance rating between the ambulatory health care center and the upper level unaffiliated tenant area. The floor/ceiling assembly is nonrated due to the chosen construction assembly.

Based on observation, on March 13, 2012 at approximately 7:30am onward, there is an unsealed penetration in the smoke barrier located above cross corridor doors near room 227(2C).

.Based on observation, on March 14, 2012 at approximately 7:30am onward, storage room areas are incomplete due to the following:

1. holes between corrugated steel decking and wall partition, and primary steel structural member is not protected from fire exposure; storage room is greater than one hundred square feet.(located near entry to medical arts at lower level of hospital)

2. no self-closing device on door to storage room - suite 1300.

3. no self-closing device on trash storage room door - near Cancer Center water heater room

Based on observation, on March 13, 2012 at approximately 7:30am onward, there is an incomplete fire rated enclosure for storage room greater than one hundred square feet in the laboratory area. The door is not minimum forty-five minute rated with listed hardware.

Based on observation, on March 14, 2012 at approximately 7:30am onward, the hyperbaric unit is not enclosed with a minimum one hour barrier - doors in existing fire door frames are not minimum B-one hour fire doors with listed self-closing and latching hardware.

Based on observation, on March 14, 2012 at approximately 7:30am onward, the means of egress components are incomplete in the following areas:

1. Exit discharge to loading dock, rear entrance to IT, is equipped with momentary off switch and no master release switch for electromagnetic locking arrangement.

2. Loading dock exit discharge at kitchen - no guardrails are provided between egress path and edge of loading dock.

3. Entry leaving view area - no sensor above access controlled egress doors.(near labor and delivery)

4. Stair #9 - delayed egress lock did not function with continuous pressure applied for three seconds to the latch release device. Lock did release with activation of the facility fire alarm system by detection devices.

Based on observation, on March 13, 2012 at approximately 7:30am onward, exit access doors throughout the facility are equipped with deadbolt locks in addition to other latching devices; such arrangements create greater than a single motion of the hand to exit areas. Latching hardware on referenced doors exceeds forty-eight inch maximum height above finished floor.

Based on observation, on March 14, 2012 at approximately 7:30am onward, exit access doors throughout the facility are equipped with deadbolt locks in addition to other latching devices; such arrangements create greater than a single motion of the hand to exit areas. Latching hardware on referenced doors exceeds forty-eight inch maximum height above finished floor.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no audible alarm for loss of normal power to the fire alarm control panel.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there are no sprinklers in the following spaces:

1. water heater closet - located in suite 1000.

2. electrical equipment room - near new linear accelerator.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no sprinkler in slave monitoring area located in old telemetry - pod 2A.

Based on observation, on March 13, 2012 at approximately 7:30am onward, there is no electrical supervision of main control valves located in above ground hot boxes near front entrance driveway, and rear driveway.

Based on observation, on March 13, 2012 at approximately 7:30am onward, there is no electrical supervision of main sprinkler control valves located in above ground valve box.

Based on observation, on March 13, 2012 at approximately 7:30am onward, sprinkler system components are noncompliant in the following areas:

1. Laboratory - debris and dust accumulation on heat sensitive element of sprinklers

2. 2A slave monitoring area - debris and dust accumulation on heat sensitive element of sprinklers

3. Lower level - high and low pressure switch valve is not electrically supervised. (in shop)

4. Lower level - high and low pressure switch valve is not supervised.( in equipment room)

5. 3B phone room - sprinkler is obstructed by fluorescent light fixture.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no heat in the provided in the above ground valve box serving the main sprinkler control valves - the heat source must be connected to the emergency power system.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no manual shut-down switch within the hospital based facility for the air handling systems serving the building.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no baffle or separation provided between deep fryers and gas range. Located in main kitchen area under the range hood fire suppression system.

Based on observation, on March 13, 2012 at approximately 7:30am onward, there are high temperature, exposed element, portable heaters used in laboratory office.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is storage in the means of egress corridor in the IT department - located on lower level.

Based on observation, on March 14, 2012 at approximately 7:30am onward, the medical gas distribution system is noncompliant due to the following:

1. oxygen tanks are not individually secured at the manifold system.

2. there is no canopy or other enclosure to protect the cylinders from extremes of weather.

Based on observation, on March 13, 2012 at approximately 7:30am onward, the facility is noncompliant due to the following:

1. Accutech system for the infant security system is connected to the Life Safety Branch of the EES(Essential Electrical System). This system is not permitted to be connected to the Life Safety Branch panel EL4E.

2. There is no low fuel level indicator when the main fuel tanks reach a three hour operating capacity. The signal must register at the generator annunciator panel located in the security area.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no low fuel level alarm registered at the generator annunciator panel.

Based on observation, on March 13, 2012 at approximately 7:30am onward, the electrical system is noncompliant due to the following:

1. ground-fault interrupter receptacle did not function in men's toilet - located at visitor's entrance.

2. two portable space heaters are connected to the same twenty amp branch circuit in the laboratory area.

3. circuit breaker CL2L4 did not interrupt power to the countertop receptacle in the laboratory area - circuit directory in panelboard must correspond to devices served.

Based on observation, on March 14, 2012 at approximately 7:00am onward, there is no tenant separation barrier of a minimum one hour fire resistance rating between the ambulatory health care center and the upper level unaffiliated tenant area. The floor/ceiling assembly is nonrated due to the chosen construction assembly.

Based on observation, on March 13, 2012 at approximately 7:30am onward, there is an unsealed penetration in the smoke barrier located above cross corridor doors near room 227(2C).

.Based on observation, on March 14, 2012 at approximately 7:30am onward, storage room areas are incomplete due to the following:

1. holes between corrugated steel decking and wall partition, and primary steel structural member is not protected from fire exposure; storage room is greater than one hundred square feet.(located near entry to medical arts at lower level of hospital)

2. no self-closing device on door to storage room - suite 1300.

3. no self-closing device on trash storage room door - near Cancer Center water heater room

Based on observation, on March 13, 2012 at approximately 7:30am onward, there is an incomplete fire rated enclosure for storage room greater than one hundred square feet in the laboratory area. The door is not minimum forty-five minute rated with listed hardware.

Based on observation, on March 14, 2012 at approximately 7:30am onward, the hyperbaric unit is not enclosed with a minimum one hour barrier - doors in existing fire door frames are not minimum B-one hour fire doors with listed self-closing and latching hardware.

Based on observation, on March 14, 2012 at approximately 7:30am onward, the means of egress components are incomplete in the following areas:

1. Exit discharge to loading dock, rear entrance to IT, is equipped with momentary off switch and no master release switch for electromagnetic locking arrangement.

2. Loading dock exit discharge at kitchen - no guardrails are provided between egress path and edge of loading dock.

3. Entry leaving view area - no sensor above access controlled egress doors.(near labor and delivery)

4. Stair #9 - delayed egress lock did not function with continuous pressure applied for three seconds to the latch release device. Lock did release with activation of the facility fire alarm system by detection devices.

Based on observation, on March 13, 2012 at approximately 7:30am onward, exit access doors throughout the facility are equipped with deadbolt locks in addition to other latching devices; such arrangements create greater than a single motion of the hand to exit areas. Latching hardware on referenced doors exceeds forty-eight inch maximum height above finished floor.

Based on observation, on March 14, 2012 at approximately 7:30am onward, exit access doors throughout the facility are equipped with deadbolt locks in addition to other latching devices; such arrangements create greater than a single motion of the hand to exit areas. Latching hardware on referenced doors exceeds forty-eight inch maximum height above finished floor.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no audible alarm for loss of normal power to the fire alarm control panel.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there are no sprinklers in the following spaces:

1. water heater closet - located in suite 1000.

2. electrical equipment room - near new linear accelerator.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no sprinkler in slave monitoring area located in old telemetry - pod 2A.

Based on observation, on March 13, 2012 at approximately 7:30am onward, there is no electrical supervision of main control valves located in above ground hot boxes near front entrance driveway, and rear driveway.

Based on observation, on March 13, 2012 at approximately 7:30am onward, there is no electrical supervision of main sprinkler control valves located in above ground valve box.

Based on observation, on March 13, 2012 at approximately 7:30am onward, sprinkler system components are noncompliant in the following areas:

1. Laboratory - debris and dust accumulation on heat sensitive element of sprinklers

2. 2A slave monitoring area - debris and dust accumulation on heat sensitive element of sprinklers

3. Lower level - high and low pressure switch valve is not electrically supervised. (in shop)

4. Lower level - high and low pressure switch valve is not supervised.( in equipment room)

5. 3B phone room - sprinkler is obstructed by fluorescent light fixture.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no heat in the provided in the above ground valve box serving the main sprinkler control valves - the heat source must be connected to the emergency power system.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no manual shut-down switch within the hospital based facility for the air handling systems serving the building.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no baffle or separation provided between deep fryers and gas range. Located in main kitchen area under the range hood fire suppression system.

Based on observation, on March 13, 2012 at approximately 7:30am onward, there are high temperature, exposed element, portable heaters used in laboratory office.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is storage in the means of egress corridor in the IT department - located on lower level.

Based on observation, on March 14, 2012 at approximately 7:30am onward, the medical gas distribution system is noncompliant due to the following:

1. oxygen tanks are not individually secured at the manifold system.

2. there is no canopy or other enclosure to protect the cylinders from extremes of weather.

Based on observation, on March 13, 2012 at approximately 7:30am onward, the facility is noncompliant due to the following:

1. Accutech system for the infant security system is connected to the Life Safety Branch of the EES(Essential Electrical System). This system is not permitted to be connected to the Life Safety Branch panel EL4E.

2. There is no low fuel level indicator when the main fuel tanks reach a three hour operating capacity. The signal must register at the generator annunciator panel located in the security area.

Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no low fuel level alarm registered at the generator annunciator panel.

Based on observation, on March 13, 2012 at approximately 7:30am onward, the electrical system is noncompliant due to the following:

1. ground-fault interrupter receptacle did not function in men's toilet - located at visitor's entrance.

2. two portable space heaters are connected to the same twenty amp branch circuit in the laboratory area.

3. circuit breaker CL2L4 did not interrupt power to the countertop receptacle in the laboratory area - circuit directory in panelboard must correspond to devices served.