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Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 7th floor North - room is open to corridor; located across from nourishment room Waiver till 12/30/2011

2. Main Building 7th floor F wing - dictation room beside glass block wall is open to corridor Waiver till 12/30/2011

3. Main Building 1st floor Ultra Sound Exam room #1 - space beside exam room is open to corridor Corrected 10/12/2011

4. Main Buildig 1st floor Ultras Sound wing - office space is open to corridor near stairwell 9 Waiver till 12/30/2011

Based on the observations and staff interviews on August 2nd, 2011 through August 4th,
2011 the following Life Safety items were observed as noncompliant, specific findings
include:

1. Main Building 6th floor CCU doctor ' s sleep area -By-fold door in exit egress corridor Corrected 10/12/2011

2. Main Building 4th floor conference room, 4th floor public safety workroom, throughout hospital -Doors with card readers in corridor did not provide positive latching while engaged Waiver till 12/30/2011

3. Main Building 3rd floor -Corridor doors and the nurses lounge for ICU Nuro & ICU suites did not have positive latching Waiver till 12/30/2011


4. Main Building 3rd floor near room C353 & near neuroscience assistant nurse manager ' s office -Corridor door hardware located higher than 48 " above finished floor Waiver till 12/30/2011

5. Main Building 2nd floor -Corridor door to " casemakeup storage " in OR (operating room) suite had tape over the strike plate.Corrected 10/12/2011

6. Main Building 2nd floor -Dutch door to the satellite pharmacy in OR had a gap between the frames and was not smoke tight. Dutch doors must comply with 19.3.6.3.6 which states that both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Waiver till 12/30/2011

7. Main Building 2nd floor -Corridor door to OR women ' s locker room, from the sterile side, did not have positive latching. Waiver till 12/30/2011

8. Main Building 2nd floor by freight elevator - Corridor door to " EVS " workroom had tape over the strike plate. Corrected 10/12/2011

9. Main Building 8th floor D wing - non passage hardware on Unisex bathroom Corrected 10/12/2011

10. Main Building 7th floor E wing - door to room E922 does not self latchWaiver till 12/30/2011

11. Main Building 7th floor E wing room E931 - door does not have positve latching hardwareWaiver till 12/30/2011

12. Main Building 7th floor F wing - improper air balance causing cross corridor doors to not close and latch properly near the nurses station Corrected 10/12/2011

13. Main Building 7th floor F wing - Exit access door near nurses station must latch with a single motion to contain fire Corrected 10/12/2011

14. Main Building 7th floor F wing - room 7820 not equipped with automatic flush bolt and self-closing deviceWaiver till 12/30/2011

15. Main Building 7th floor North wing near the South Courtyard - the locking mechanism must open with a single motion of the handWaiver till 12/30/2011

16. Main Building 1st floor Radiology wing - non latching hardware on doors to Interventional Radiology Control room, Neuro Angio Interventional 1, Angio Interventional Exam room 3Waiver till 12/30/2011

17. Main building 2nd floor wing short C hall pathology office door witch is on the corridor and did not latching hardware installed on the door.Waiver till 12/30/2011

18. Main building 5th floor wing C room C580 witch is on the egress corridor and did not have latching hardware installed on the door. Corrected 10/12/2011

19. Main building 5th floor West wing electrical room is on the egress corridor and did not have positive latching installed the door. Corrected 10/12/2011

20. Main Building fourth floor, C wing -The facility has a bathroom / closet door in room C455 that when opened blocks the main corridor room door from closing. Waiver till 12/30/2011

21. Main Building fourth floor, C wing - The facility has a bathroom / closet door in room C457 that when opened blocks the main corridor room door from closing. Waiver till 12/30/2011

22. Main Building fourth floor, C wing -The facility has a bathroom / closet door in room C457 that when opened blocks the main corridor room door from closing. Waiver till 12/30/2011

23. Main Building fourth floor, C wing -The facility has a bathroom / closet door in room C445 that when opened blocks the main corridor room door from closing. Waiver till 12/30/2011

24. Main Building fourth floor, C wing -The facility has a bathroom / closet door in room C447 that when opened blocks the main corridor room door from closing. Waiver till 12/30/2011

25. Main Building ground floor, C wing -The facility is utilizing an expandable gate verses a solid door in the corridor in a facility that is not fully sprinklered. Waiver till 12/30/2011


26. Main building, 3rd floor Caner Center, the clean utility room which is on the egress corridor has a door without positive latching. Corrected 10/12/2011

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 7th floor E wing smoke barrier doors did not open in opposite directions near adult behavior entrance Waiver till 10/30/2011

2. Main Building 2nd floor PICU wing, cross corridor doors did not close smoke tight at Metro view Tower.Corrected 10/12/2011


3. Main building 2nd floor Family Center cross corridor on left side did not close with activation of fire alarm.Waiver till 10/30/2011

4. Main building, 3rd Floor, 3A, the cross corridor door at the dietary elevator area did not close upon activation of the fire alarm system. (Door 3a-23)Waiver till 10/30/2011

5. Main building, 3rd floor, Harris Hospice. The facility has cross corridor smoke doors at H31, and H32 that had a gap grater than 1/8th of an inch when closed.Waiver till 10/30/2011

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Metroview, Sleep Center, 3rd floor, the soiled linen closet located in the unit is not one hour construction or sprinkled. Waiver till 10/30/2011

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 8th floor D wing storage room equipped louvered doors in Storage room Waiver till 11/30/2011

2. Main Building7th floor D wing storage room door is not a fire rated doorWaiver till 11/30/2011

3. Main Building7th floor C wing soiled linen door not self closing and latching near the Bio Hazard room Corrected 10/12/2011

4. Main Building3rd floor -Shaft to soiled linen chute was not sprinklered nor had smoke detection. Room had sprinkler piping that had been caped off, without the sprinkler head. Corrected 10/12/2011

5. Main Building Fourth floor, B wing -The facility is utilizing a non rated door at hazardous material room B429. Corrected 10/12/2011

6. Main building, 1st floor, Senior Administration; The ceiling in the IT room has holes that were not sealed to maintain the required rating of the room. Waiver till 11/30/2011

7. Main building, 1st floor, Kitchen Area. The doors to dry storage area witch is a hazardous area located next to catering office area are not self-closing or one hour rated. Waiver till 11/30/2011

8. Main Building, 5th floor, 5F Hall, The facility is using a soiled utility room as soiled lined room. This room will now need to be one hour or sprinkled. Corrected 10/12/2011

9. Main Building, 1st floor, compresses gas storage room at rear exit near dietary. Room holds more than 3000 cu. ft. of compresses gas, does not have mechanical exhaust ventilation and is not sprinkled. The area is considered a sever hazard and will need to be one hour and sprinkled. Waiver till 11/30/2011

10. Main building 3rd floor, mechanical area, (open air area) next to AA elevator is used for storage and the area is not sprinkled, Waiver till 11/30/2011

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 6th floor stairwell 6 & 7 in ER overflow, stairwell 1, 4, & 2 in endoscopy -Delayed egress with electric strike plate, no longer in use, should be rendered no longer capable of reengaging with the turn of a key. Corrected during survey Corrected 10/12/2011

2. Main Building 2nd floor -Exit access blocked by vapor barriers of OR ' s new construction. Exit must not exceed 100 feet to stairwell. Corrected during survey.Corrected 10/12/2011

3. Main Building 2nd floor near children ' s elevator -Special locking could be reengaged/relocked with fire alarm system in alarm mode. Waiver till 12/30/2011

4. Main Building 2nd floor entrance to children ' s wing from hospital - Special locking did not release with fire alarm or smoke head activation Waiver till 12/30/2011

5. Main Building 7th floor D wing - magnetic lock near 7D elevator must have a manual override not more than 3 feet from the door Waiver till 12/30/2011

6 Main Building 7th floor F wing - access control egress door at ICN Entrance is a magnetic lock and has a push pad without additional features as required for access controlled egress doors in the Life Safety Code. Waiver till 12/30/2011

7. Main Building 7th floor F wing - no emergency release in ICN nurses station for special locking arrangements. Waiver till 12/30/2011

8. Main Building 7th floor North wing - egress corridor exceeds twenty feet from a point where two exits can be reached. The corridor is located near cross corridor doors between service corridor and Women's Center. Waiver till 12/30/2011

9. Main Building 1st floor Emergency Department - delayed egress doors not operating properly at the back of the Pediatric unit Waiver till 12/30/2011

10. Main Building 1st floor Emergency Department - access control egress door push control must be within 5 feet to operate near the Pediatric unit Waiver till 12/30/2011

11. Main Building 1st floor Emergency Department - horizontal entrance doors do not break away properly in the direction of egress Corrected 10/12/2011

12. 1st floor CT wing - access control egress door push control must be within 5 feet of access control doors. Located near the CT Entrance Waiver till 12/30/2011

13. Main Building 1st floor Radiology unit - dead end corridor is more than 20 feet from point were exits may be reached. Located near MRI. Waiver till 12/30/2011


Note: Special locking arrangements are permitted only in facilities equipped throughout with a complete sprinkler or detection system. The facility on the date of this survey was not equipped with the required systems.

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 8th floor D wing - unprotected vertical opening in stairwell 6 Waiver till 12/30/2011

2. Main Building 7th floor D wing - unprotected vertical opening in stairwell 6 Waiver till 12/30/2011

3. Main Building 1st floor Stairwell 3 - swing bar between landing and stairs to lower level obstructs stairway landing. The swing bar was not self-closing at time of survey.Corrected 10/12/2011

4. Main Building, 2nd floor, stairwell 15, (PICU) The facility has storage in closet in stairwell. Waiver till 12/30/2011

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 2nd floor -Door to OR storage required more than a single range of motion to exit the room. Waiver till 4/30/2012

2. Main Building 8th floor D wing - guardrail must be a minimum of 42 inches high and prevent the passage of a 6 inch spear; located near the exit access serving the elevator equipment room.Waiver till 4/30/2012

3. Main Building 7th floor D wing - locks located higher than 48 inches on rooms D793, D787, Medical director officeWaiver till 4/30/2012

4. Main Building 1st floor Radiology wing - locks located higher than 48 inches in Interventional Radiology hallway Waiver till 4/30/2012

5. Main Building 1st floor Diagnostic Radiology - excessive hardware on door requires more than one motion of the hand to exit at Diagnostic 1 Waiver till 4/30/2012

6. Main Building 1st floor Diagnostic Radiology - door is less than 41 1/2 inches clear opening at Diagnostic 2 Waiver till 4/30/2012

7. Main Building, ground floor, C wing -The facility is utilizing more than one motion of the hand for egress at Cancer data Services closet to fire exit. Waiver till 4/30/2012

8. Main building 5th floor E wing. The facility is utilizing more than one motion of the hand for egress at the CURY unit. Waiver till 4/30/2012

9. Main building 5th floor E wing. There is no emergency release switch located in the vicinity of the special locking doors, nor a master switch to release the doors at the nurses station. Waiver till 4/30/2012

10. Main building 5th floor E wing C unit, The facility is utilizing more than one motion of the hand for egress from this unit at both doors in the unit. Waiver till 4/30/2012

11. Main Building 5th floor E wing Cath Lab. The facility dows not have a door release switch at the nurse station for the special locking doors serving that location. Waiver till 4/30/2012

12. Main building 2nd floor Hemby unit. The facility is utilizing more than one motion of the hand for egress from all office doors at this location. Waiver till 4/30/2012

13. Main building 2nd floor Pathology unit. The facility is utilizing more than one motion of the hand for egress from the vent hood room. Waiver till 4/30/2012

14. Main Building 4th floor C wing -The facility is utilizing more than one motion of the hand for egress at the staff lounge across from room C443. Waiver till 4/30/2012

15. Main Building 4th floor B wing - The facility is utilizing more than one motion of the hand for egress at room B430. Waiver till 4/30/2012

16. Main Building, ground floor, C wing -The facility is utilizing more than one motion of the hand for egress at Cancer data Services closet to fire exit. Waiver till 4/30/2012

17. Main Building, ground floor, C wing -The facility is utilizing more than one motion of the hand for egress at Cancer data Services near the corridor fire doors. Waiver till 4/30/2012

18. Main Building, ground floor, C wing - The facility is utilizing more than one motion of the hand for egress at occupational therapy room. Waiver till 4/30/2012

19. Main Building, ground floor, C wing -The facility is utilizing more than one motion of the hand for egress at Hydrotherapy room. Waiver till 4/30/2012


20. Main building,1st Floor, Kitchen; The means of egress outside the exit door next to cooler #1 and to the upper lever loading dock was blocked and not maintained clear and unobstructed. Waiver till 4/30/2012

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 2nd floor - Illumination of means of egress/ exit discharge lighting in the " old dock " egress from materials management to the public way was not on the life safety branch of the emergency electrical system. Waiver till 11/30/2011

2. Main Building Illumination of means of egress/ exit discharge lighting around the perimeter of the building was on a timer and could not be verified to come on with the emergency power system during daylight hours. Waiver till 11/30/2011

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Metroview, Sleep Center, 3rd floor, The Sleep Center was not equipped A fire alarm system in accordance with Section 9.6 Waiver till 2/28/2012

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building Ground floor pharmacy storage room -There was no sprinkler nor smoke detection at the pharmacy storage Corrected 10/12/2011

2. Main building ground Floor outpatient surgery -There was no sprinkler coverage nor smoke detection at the pack U and recovery area Corrected 10/12/2011


3. Main building 2nd floor B wing staff closet had storage within 18 inches of sprinkler head.Corrected 10/12/2011

4. Main building 2nd floor Pathology. The facility is utilizing special locking systems and does not have sprinkler coverage in the Pathology closet. Waiver till 8/30/2012

5. Main building 7th floor IT closet. The facility is utilizing special locking systems and does not have sprinkler coverage in the IT closet. Waiver till 8/30/2012

6. Main building 7th floor Dr. sleep room, The facility is utilizing special locking systems and does not have sprinkler coverage in the doctors sleep room. Waiver till 8/30/2012

7. Main Building, ground, outside the emergency entrance -The facility is utilizing heat tape instead of electronic heating elements on the emergency power supply on back flow valves. Waiver till 8/30/2012

8. Main Building, ground floor, Kitchen walk-in cooler -The facility us utilizing special locking devices and does not have its walk-in cooler sprinklered. Waiver till 8/30/2012

9. Main building, 3rd floor, 5A area, the patient bathroom are equipped with sprinklers but the shower located in the bathroom area not protected due to the location of the sprinkler head against the bulkhead not prevent proper coverage in the area. Waiver till 8/30/2012

10. Main building 5th floor, F wing, the curtains in the patient showers do not provide the 18 inch separation at the ceiling or have the mesh top that will allow for proper coverage of the shower. Waiver till 8/30/2012

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building, Ground Floor, Outside near the emergency entrance -The tamper alarm 113 did not give an audible and visual alert at an area where it was likely to be heard. Waiver till 12/30/2011

2. Main building, Ground floor parking garage maintenance room -The facility does not have its pressure operated flow switch on the dry pipe sprinkler system supervised. Waiver till 12/30/2011

3. Main Building, Ground Floor, at Fourth Street -The facility does not have its post indicator valve on the Fourth Street location Waiver till 12/30/2011

4. Main building ground floor Fourth Street -There is an unapproved tamper alarm at the sprinkler at the fourth street location. Waiver till 12/30/2011

5. Main building ground floor stairwell # 8 -There is an unapproved tamper alarm at the sprinkler at stairwells 3 and 8. Waiver till 12/30/2011

6. Main building, Ground floor Emergency Department Sprinkler room -The facility does not have its pressure operated flow switch on the dry pipe sprinkler system supervised. Waiver till 12/30/2011

7. Main building, Sub-Basement, Gift shop storage area, there is an unapproved tamper alarms at the sprinkler valves at this location. Waiver till 12/30/2011

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 8th floor on D wing - light fixture obstructing sprinkler in Storage room Waiver till 2/28/2012

2. Main Building8th floor on D wing - obsruction of sprinkler by file cabinet in File room Waiver till 2/28/2012

3. Main Building8th floor on D wing in Juvenile Recreation Area - obstruction of sprinkler near Unisex bathroom Waiver till 2/28/2012

4. Main Building7th floor on F wing in change out room - solid shower curtain obstructing sprinkler Waiver till 2/28/2012

5. Main Building7th floor on F wing in clean linen room - sprinkler escutheon is blocking sprinkler deflector Corrected 10/12/2011

6. Main Building1st floor Admissions area - storage within 18 inches of sprinkler in office by Interview room 7 Corrected 10/12/2011

7. Main building ground floor engineering storage -There was a blocked sprinkler head at the EV ' s bed storage portion of the storage room at the concrete beam and the conduit below it. Waiver till 2/28/2012

8. Main building ground floor D wing -There was a blocked sprinkler head by duct work near the records room near the outside exit door. Waiver till 2/28/2012


9. Main building, 1floor, Outside canopy in front of the Cancer Center. The sprinkler heads were corroded and were not maintained in good condition. Corrected 10/12/2011

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 7th floor E wing - fire damper in electrical room is not installed in accordance with manufacturer's installation instructions. Duct penetrating floor assembly is not equipped with breakaway connections. Waiver till 2/28/2012

2. Main Building Behavioral Health Unit - there is no emergency shutdown switch for air handler serving the unit. Waiver till 2/28/2012

3. Main building 5th floor C wing short hall staff could not located shut down button for HVAC system. Waiver till 2/28/2012

4. Main Building 5th floor Cat lab and Nick U. staff could not located shut down button for HVAC system. Waiver till 2/28/2012

5. Main building, 1st Floor, Radiological Oncology, facility could not locate the HVAC emergency shutdown switch that serves the area. Waiver till 2/28/2012

6. Main building, 3rd floor, outpatient infusion, facility could not locate the HVAC emergency shutdown switch that serves the area. Waiver till 2/28/2012

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Main building, 1st Floor, Kitchen, the hood and exhaust make-up air supply for the unit located by the baking ovens did not appear to be operational. Waiver till 10/30/2011

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 7th floor North wing slef latching device needed on laundry chute in soiled utility # 5 Waiver till 10/30/2011

2. Main Building 6th floor -Two hour enclosure for the interstitial space at the transfer grill did not have smoke detectors on both sides for automatic closure of grills upon activation. Waiver till 10/30/2011

3. Main Building 6th floor -Two hour enclosure for the interstitial space (with the pneumatic chute) did not use both fire/smoke dampers in the transfer grill for air handling unit 24. Only fire dampers were installed. Waiver till 10/30/2011

4. Main Building the two hour enclosure for pneumatic soiled linen chute as it passes from 6th to 7th floor in the interstitial space of the 6th floor was not provided. Waiver till 10/30/2011

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 8th floor D wing -obstruction of the means of exit egress in greenhouseCorrected 10/12/2011

2. Main Building 7th floor C wing -storage in 8C short hallwayCorrected 10/12/2011

3. Main Building 7th floor C wing -wall mounted clerical pads near 764 and 767 not functioning properlyCorrected 10/12/2011

4. Main Building 7th floor C wing -blind spot mirror mounted on corridor wall protrudes inside 6ft 8in head clearance near stairwell 8Corrected 10/12/2011

5. Main Building 7th floor E wing - access door to room E922 obstructs corridor Waiver till 10/30/2011

6. Main Building 7th floor North wing - crash carts disrupt flow of corridor outside O2 room and rooms 866 and 860 Waiver till 10/30/2011

7. Main Building 1st floor Interventional Radiology - hallway lights in corridor protrude inside 6ft 8in head clearance Waiver till 10/30/2011


9. Main Building 1st floor Radiology Wing -breakaway doors at entrance to MRI protrude further than 7inches from the wall Waiver till 2/28/2012

10. Main Building 6th floor near room A624 - Wall mounted charting table located near room A624 did not return to the upright position when placed down for use. Corrected 10/12/2011

11. Main building 5th floor , D wing. The facility has items obstruction the egress corridor at C.O.W. Corrected 10/12/2011

12. Main building 5th floor , D wing B/P has items obstructing the egress corridor at the D wing B/P area. Corrected 10/12/2011

13. Main building 2nd floor short C hall. The janitor closet door opens into the egress corridor and does not have either a self closing device installed to close the door when opened or open 180 degrees onto the egress corridor. Waiver till 10/30/2011

14. Main building fourth floor, D wing -Charting table located near rooms D448 D494, D486, D487 did not return to the upright position when placed down for use. Corrected 10/12/2011

15. Main building, 5th Floor, intersection of 5A and 5F there is storage in the exit egress corridor located next to Stairwell 14, (Linen cart and stretcher)Corrected 10/12/2011

16. Main building, 5th floor, intersection of 5A and 5C, plastic dust barrier protruding into the corridor blocking the means of egress. (Corrected during survey)Corrected 10/12/2011

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Midtown Surgery Center 7th floor Surgery unit - only one master alarm panel for medical gas system is provided in the facility. Waiver till 11/30/2011

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Main Building 7th floor Surgery unit - generator annunciator panel is not located within ambulatory surgery center at a supervised station Waiver till 11/30/2011

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 8th floor D wing electrical outlet is not GFI protected in the greenhouse Waiver till 11/30/2011

2. Main Building 8th floor D wing light is not on the life safety branch in the greenhouse Waiver till 11/30/2011

3. Main Building 7th floor C wing Lights in Medx (medication preparation room) was not verified to be on emergency powerCorrected 10/12/2011

4. Main Building 7th floor C wing room 769 red switch for nightlight not operationalCorrected 10/12/2011

5. Main Building 7th floor F wing exposed bulbs in storage room near elevator FCorrected 10/12/2011

6. Main Building 7th floor North wing recepticals were loose and had dust buildup in OR2 and OR3Corrected 10/12/2011

7. Main Building 1st floor Radiology wing electrical outlet is not GFI protected in Inpatient Recovery Holding areaCorrected 10/12/2011

8. Main Building 1st floor Nuclear Medicine wing 3 way switch near Nuclear Medicine 5 is not working properlyCorrected 10/12/2011

9. Main Building 1st floor Emergency Department entrance circuit breaker FACP on normal powerCorrected 10/12/2011

10. Main Building maintance shop in main building EPS supplying load did not funcation during normal loss of power Waiver till 11/30/2011

11. Main Building Ground floor switchboard room - The generator annuciator panel did not give an audible signal when the facility went from normal to emergency power when the emergency power system was tested. Waiver till 11/30/2011

12. Main building ground floor switchboard room -The generator annuciator panel lamp test did not give an emergency trouble visual indication of system trouble when tested during the emergency power system test. Waiver till 11/30/2011

13. Main Building 2nd floor -Confirm PACU pixus and blood bank #22 in OR on emergency power. Corrected 10/12/2011

14. Main building 5th floor C wing. The facility has an open J box above the ceiling at double doors labeled FDO-5R-217Corrected 10/12/2011

14. Main building 2nd floor PICU. The facility has a medical refrigerator which was not verified to be on emergency power.Corrected 10/12/2011



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16. Main building, 1st Floor, Kitchen . The light in the cooler is missing the protective cover over the bulb.Corrected 10/12/2011

17. Main building, 1st Floor, Kitchen. Two refrigeration units one located on the cook line under the hood and one located next to the tray make-up area were equipped with unapproved wiring. (Non manufactured approved wiring/cords and non approved quad receptacle box)Corrected 10/12/2011


18. Main building, 1st Floor, Kitchen. The electrical panel located in the dishwashing area were blocked and not provided with the required clearance.Corrected 10/12/2011

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Basement of Midtown Medical Center - fire alarm control panel is not connected to the life safety branch circuit and is not identified on the fire alarm panel. Waiver till 11/30/2011

2. The surgery center electrical system is not installed as required for a type 1 essential electrical system serving a surgery center that utilizes general anesthesia.Waiver till 11/30/2011