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Based on observations and staff interviews, the facility failed to maintain the fire resistance of fire barriers and communicating openings with an approved UL system per the requirements of 2012 NFPA 101, 19.1.3.3(2) and 8.3.5.1. This has the potential to affect 18 of 83 observed smoke compartments.

The findings include:

1. Observations and interviews with the maintenance staff on 9/11/17 between 10:40 AM and 4:00 PM revealed firestopping in 2-hour walls and 3-hour rated floors were not per an approved UL system at the following locations:

a. The 6th floor 2-hour separation from the medical resident sleep area above the cross corridor doors, the firestopping was not an UL approved system. The penetrations were sealed with a red fire caulk and a sprayed on product applied over. No approved UL fire stop system or engineering judgement was provided.

b. The 5 North 2-hour separations above the cross-corridor doors were improperly fire stopped with a red fire caulk and a sprayed on grey product applied over it. No approved UL fire stop system or engineering judgement was provided.
c. The cross corridor 2 hour firewall at EPSDR 02522 the penetrations were sealed with black and red caulk. No approved UL fire stop system or engineering judgement was provided.

d. The east tower penthouse had an unsealed 2-inch metal sleeve through the floor.

2. Observations on 9/11/17 at 11:35 AM, revealed mixed fire caulk above the cross corridor doors of the fire barriers in the following areas and no approved UL fire stop system or engineering judgement was provide.:
a. near room 633 (x2)
b. near critical care waiting room
c. near L&D operating room (OR) -03
d. near Interventional Radiology #6
The Director of Facilities Planning & Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observation and interview, the facility failed to ensure corridor doors closed to a positive latch per the requirements of:
2012 NFPA 101, 8.3.3.1
2010 NFPA 80, 6.1.4.2.1
This has the potential to affect 2 of 83 observed smoke compartments.

The findings include:

Observation on 9/12/17 at 1:20 AM, revealed the cross corridor doors located by the Magnet Program Directors office was not shutting properly (hitting door frame).

The Director of Facilities Planning & Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observations and interviews, the facility failed to provide illuminated exit signage per the requirements of NFPA 101 19.2.10.1, 19.7.6 and 7.10.5.1. This has the potential to affect 3 of 83 observed smoke compartments.
The findings include:
Observations and interviews with the maintenance staff on 9/12/17 between 8:24 AM and 10:46 AM revealed;

1. The exit sign in the operating room corridor by operating room (OR) 25 was not illuminated.
2. The exit sign in the operating room corridor by OR 17 was not illuminated.
3. There were no exit signs inside the Lab to doors leading to the egress corridors.

The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observations and interviews, the facility failed to maintain vertical openings per the requirements of 2012 NFPA 101, Sections 8.3.4.2, 9.2.3, 19.3.1.1 through 19.3.1.6, and 19.3.2.5.1. This has the potential to affect 9 of 83 observed smoke compartments.

The findings include:

1. Observations and interviews with the maintenance staff on 9/11/17 between 1:00 PM and 3:30 PM revealed;

a. The 3rd and 4th floor interior stairwell two hour stairwell shaft had a sprinkler pipe penetration that was sealed with red and black mixed caulking. An approved UL system could not be provided.
b. The 3 West 1-1/2 hour trash chute door failed to close to a positive latch.
c. The 2 West 1-1/2 hour trash chute door failed to close to a positive latch.
d. The 1 West 1-1/2 hour trash chute door failed to close to a positive latch.
e. The 2 West Bio Med room mechanical pipe chase's 1-1/2 fire access door failed to close to a positive latch.

2. Observation and interview with the maintenance staff 9/12/17 at 1:33 PM, revealed the stairwell fire door #EPFDR02101 latch was broken.
The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observations and interviews, the facility failed to ensure hazardous area doors would resist the passage of smoke per the requirements of NFPA 101 2012 Ed. 19.3.2.1 and 19.3.2.1.2. This deficiency affected 1 of 83 smoke compartments.

The findings include:

Observations in the dietary department, on 9/11/17 at 3:50 PM revealed the following:
a. The dietary dry storage chemical room door is louvered and not smoke resistant
b. The dietary dry storage chemical room walls are not smoke resistant with an unsealed penetration around a pipe.
The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observation and interview, the facility failed to ensure kitchen hood suppression system was maintained per the requirements of 2012 NFPA 101 sections 19.3.2.5, 9.2.3 and 2011 NFPA 96 10.2.7.4. This has the potential to affect 1 of 83 observed smoke compartments.

The findings include:

1. Interview with the dietary manager on 9/11/17 at 3:30 PM revealed a deep fat fryer was added under kitchen hood without re-evaluation of the system to assure the suppression system is designed and sized adequately.

2. Observation on 9/11/17 at 4:05 PM revealed a convection oven in the first floor dietary department is not installed under an exhaust system. The convection oven is used for cooking food products that produce grease laden vapors.

The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observation and interview, the facility failed to ensure rolling steel fire doors were provided with automatic closing devices per the requirements of:
2012 NFPA 101 19.2.1, 19.2.2.2.7, 7.2.1.8.2 (3) ,
2010 NFPA 72, 17.7.5.6.6 and
2010 NFPA 80, 11.4.1.2 which states:
" Rolling steel doors shall close automatically upon activation or release of a fusible link or detector."
This has the potential to affect 4 of 83 observed smoke compartments.

The findings include:

Observation on 9/11/17 at 1:40 PM revealed the roll down doors separating the 5 south PCU and MCC suites did not have smoke detector activation within 5 ft. of the door.
The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observations, the facility failed to ensure sprinkler heads were installed per the requirements of:
2012 NFPA 101 Sections 19.3.5.1, 9.7.1.1, 9.7.5, 19.7.6, 4.6.12 and
2010 NFPA 13 Section 8.1
This deficiency affected 2 of 83 smoke compartments.
The findings include:
1. Observation on 9/11/17 at 2:24 PM, revealed two (2) sprinklers inside the L-3 mechanical room across from the dialysis room were removed and the sprinkler pipe were plugged.
2. Observation on 9/12/17 at 10:53 AM revealed compressed cylinder storage room off of loading dock not provided with sprinkler protection.
The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observations, the facility failed to ensure sprinkler heads were maintained per the requirements of:
2012 NFPA 101 Sections 19.3.5.1, 9.7.1.1, 9.7.5, 19.7.6, 4.6.12
2010 NFPA 13 Section 8.3.3.2., , 8.5.4.2
2011 NFPA 25 Sections 5.2.1.1.2(2), 5.2.1.1.2 (5), , 5.2.2.2
This deficiency affected 9 of 83 smoke compartments.
The findings include:
1. Observation on 9/11/17 at 10:51 AM, revealed painted or corroded sprinklers inside the following areas:
a. Bathroom of the 7th floor nurses specialist bathroom
b. Bathroom of room 757
c. Mechanical Room L-3 across from dialysis

2. Observation starting on 9/11/17 at 1:20 PM and ending on 9-12-17 at 1:05 PM, revealed sprinklers loaded with foreign material (lint and trash) in the following areas:
a. Critical care waiting room (1 of 8 sprinklers)
b. Coffee Shop (near information desk) (4 of 7 sprinklers)
c. Trash and linen shoot 5 south MCC soiled Utility
d. Trash chute 3 south Housekeeping room
e. Linen chute 3 south soiled linen room
f. Trash chute in Bio Hazard room near gift shop
g. Elevator pit NP07 (pathology elevators) (2 of 2 sprinklers)
h. Trauma elevator pit (2 of 2 sprinklers)
i. Sprinkler head loaded with foreign material heart hospital elevator pit on the PT side.

3. Observation on 9/11/17 at 10:57 AM revealed 6th floor lab had a 8" round duct resting on sprinkler piping (NFPA 25, 5.2.2.2)

4. Observation on 9/11/17 at 11:30 AM revealed 5th floor north Physical therapy room sprinkler not parallel with the ceiling (NFPA 13, 8.5.4.2).

5. Observation on 9/11/17 at 4:00 PM revealed 10 corroded sprinkler heads around the kitchen hood and dish wash area of the ground floor dietary department.
The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observations and interviews, the facility failed to ensure the construction of corridor walls would resist the passage of smoke per the requirements of 2012 NFPA 101 sections 19.3.6.2.3 and 8.3.1.3. This deficiency affects 4 of 83 smoke compartments.

The findings include:

Observations and interviews with the Maintenance staff, on 9/11/2017 and 9/12/2017 revealed the following corridor wall locations that were not smoke resistant:

1. The smoke barrier wall above the supply room door located near room 655 had an 8 inch hole.

2. Above the zone valve near L&D OR#2 had a 4x8 in hole.

3. Trash chute room across from room 1028 has unsealed concrete penetrations above the ceiling tiles from conduit and communication wiring.

4. Trash chute room across from room 1128 has unsealed concrete penetrations above the ceiling tiles from conduit and communication wiring.

The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observations, the facility failed to ensure corridor doors closed to a positive latch per the requirements of NFPA 101 section 19.3.6.3.5. This deficiency affects 4 of 83 smoke compartments.

The findings include:

Observations with the maintenance staff on 9/11/17 between 1:30 PM and 4:00 PM revealed the following corridor doors failed to close to a positive latch:

1. Trauma/surgery doors 17, 18 and 20.
2. Labor and delivery room 11.
3. 4 West room 489
4. 4 East Med room door, latch failed to retract.

The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observations and interviews, the facility failed to ensure transfer grills were not used in corridor walls regardless of whether they are protected by fusible link fire dampers per the requirements of 2012 NFPA 101, 19.3.6.4.1. This deficiency affects 4 of 83 smoke compartments.

The findings include:

Observations and interviews with the Maintenance staff, on 9/12/2017 between 10:30 AM and 1:30 PM revealed air transfer grills were located in the egress corridor walls in the following locations:

1. Adjacent the elevator lobby on 4 East,
2. Adjacent the elevator lobby on 5 East,
3. Adjacent the elevator lobby on 6 East,
4. Adjacent the elevator lobby on and 7 East.

The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observations and interviews, the facility failed to prohibit portable space heaters per the requirements of 2012 NFPA 101, 19.7.8.
This deficiency affects 5 of 83 smoke compartments.

The findings include:

Observations and interviews between 9/11/2017 at 1:20 pm and ending on 9/12/2017 at 11:32 PM, revealed the use of non-approved space heaters in the following areas:

a. Critical Care Waiting room receptionist
b. Medical Record Transcript area
c. Medical Records back room (x3)
d. Medical Records big room
e. Environmental Services Directors office

The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observations, the facility failed to ensure medical gas piping was not in direct contact with dissimilar metals in various locations per the requirements of 2012 NFPA 101, 19.3.2.4 and 2011 NFPA 99, 5.1.10.11.2, 5.1.10.11.24.4. This deficiency affects 8 of 83 smoke compartments.

Observations on 9/11/17 between 10:56 AM though 9/12/17 at 2:17 PM revealed medical gas piping touching dissimilar metals in various locations above ceiling at the following areas:
a. Room 757
b. 5th floor room 20 zone valve
c. Room 537
d. Room 538
e. Room 451
f. Corridor near the Basement floor of trauma elevator
g. Equipment room L5
h. Basement near elevator NP07
i. EVS/Laundry Corridors.
The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observation and interview, the facility failed to ensure Medical gas Zone valves were labeled with chemical symbol, gas system, room or area served, and caution not to use the valve except in an emergency per the requirements of 2012 NFPA 99, 5.1.4.8.8.
This deficiency affected 2 of 83 smoke compartments.

The findings include:

1. Observation and interview with the Maintenance staff, on 9/11/2017 at 2:03 PM revealed the zone valves for the MRI suites next to MRI room #3 was not properly labeled with chemical symbol, gas system, room or area served, and caution not to use the valve except in an emergency.

2. Observation and interview with the Maintenance staff, on 9/11/2017 at 2:09 PM revealed the zone valves for the MRI women's room was not properly labeled with chemical symbol, gas system, room or area served, and caution not to use the valve except in an emergency.
The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observations, the facility failed to ensure temporary (less than 90 days) electrical wiring was in accordance with the requirements of:
2012 Edition NFPA 101, 19.5.1.1, 9.1.2
2011 NFPA 70, 590.3, 590.6
NFPA 99 2012 Edition, 5.1.4.8.8
This deficiency affected 1 of 83 smoke compartments.

The findings include:

Observation on 9/11/17 at 10:24 AM revealed an extension cord being used as permanent wiring to power a sump pump inside the 20-2 air handler inside the L-11 Equipment Room.
The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observations and interviews, the facility failed to ensure GFCI outlets were located in all wet areas per the requirements of:
2010 NFPA 70, 210.8, 517-20, 590.3, and 590.6. This deficiency affected 4 of 83 smoke compartments.

The findings include:

Observations and interviews with the Maintenance staff on 9/12/17 between 11:00 AM and 1:30 PM confirmed GFCI outlets were not provided in the following areas:
1. 8 East soiled utility hopper rooms
2. 9 East soiled utility hopper rooms
3. 10 East soiled utility hopper rooms
4. 11 East soiled utility hopper room
5. Physical therapy breakroom by the sink
6. L-11 Equipment Room sump pump inside the 20-2 air handler
The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.

Based on observation and interview, the facility failed to ensure medical gas cylinder manifold rooms were protected by 1-hour fire rated construction per the requirements of 2012 NFPA 99; 5.1.3.3.2.(4). This deficiency affected 1 of 1 observed egress corridors exiting from the licensed portion of the facility.

The findings include:

Observation with the Safety Director and Surgery Assistant Administrator on 9/11/2017 at 11:20 AM confirmed the medical gas manifold room had two unprotected openings as large as 12" x 12" in the 1-hour wall assembly where insulated pipe was run through the wall. 1 of 2 of these openings exposed the corridor system.

The maintenance director was present when the deficiencies were identified and acknowledged by the Administrative staff during the exit conference on 9/11/2017.

Based on observations and interviews, the facility failed to maintain the oxygen storage areas per the requirements of 2012 NFPA 99, 5.1.3.3.2(10) and 11.3.4.2. This deficiency affected 2 of 83 smoke compartments.

The findings include:

Observations and interviews with the Maintenance staff on 9/12/17 between 11:00 AM and 9/12/2017 at 1:30 PM revealed:

1. The oxygen storage rack on the 3rd floor (section 3.4) was located against an unprotected outlet.

2. The oxygen storage rack in the operating room oxygen storage area was located against an unprotected outlet

3. The oxygen storage room in the emergency department was not provided with the required precautionary signage.

4. The oxygen storage area on the loading dock was not provided with the required signage.
The Director of Facilities Planning and Construction Services, Director of Maintenance, Director of Safety and other Administrative staff were present when the deficiencies were identified and acknowledged by the Vice President of Facilities Operations during the exit conference on 9/13/2017.