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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12./11, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result in delayed response to fire/smoke conditions which compromise the facility's use of the exit access corridors.

Findings include:

A. Corrected 06/28/12

B. The 1st floor 1980 building Main Lobby Waiting areas, Registration area and Lab Draw space are open to the corridor. These spaces have varying ceiling heights and configurations. The smoke detection provided is not adequate to protect each space individually to comply with 19.3.6.1 Exceptions No.1 and 2.

06/28/12 - the above item was not corrected.

1) Smoke detection is not installed throughout the entire space; spacing for smoke detection does not protect the entire space and is not installed in according with the spacing requirements for NFPA 72.

2) There is an outpatient blood draw area semi concealed in a space that is open to the Main Lobby. This space constitutes "patient treatment" and is not separated from the Main Lobby by a corridor wall and corridor door.

C. Corrected 06/28/12

D. Corrected 06/28/12

End

Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:

A. Corrected 06/28/12

B. Corrected 06/28/12

C) (New 6/28/12) There is an unrated chase behind the Electrical Closet at the west side of the 1st Floor Lab.

1) The walls of the chase are drywalled on the outside only. One hour fire rated construction is not provided in accordance with 8.2 of NFPA 101 and in accordance with NFPA 90A.

2) There are also voids in the shaft wall construction.

3) One insulated duct penetrates the mechanical room floor above and the floor below. Regardless of whether fire dampers are installed, the provider is unable to demonstrate why a one hour fire rated shaft enclosure is not required in accordance with NFPA 90A

4) Multiple ducts penetrate the mechanical room floor (not a penthouse) above- fire dampers need to be confirmed at these floor penetrations.

End

K021 New

A) (New 6/28/12) The 1st floor Lab suite northwest double egress door has a door closer with a hold open device that is not designed to release the door upon activation of the fire alarm system. Also, a smoke detector is not installed within five feet of the door in accordance with 7.2.1.8.

Failure to install and maintain fire doors could result in spread of fire and smoke to patient areas.

End

K025 (New)

A) From observation, the surveyor finds that the Lobby Level of the Lobby Level of the 1980 Building was very recently renovated. The specifics of this renovation are not available. However, based on the extent of renovation, the surveyors find that 18.3.7.1 (2) is applicable. The provider has not demonstrated how two smoke compartments are provided in accordance wit 18.3.7.1.

It is the intent of this citation to remove the information provided in the PoC under K038 G and to revise and resubmit the information under K025.

End

Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients of the smoke compartment, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:

A. Corrected 06/28/12

B. The 3rd floor 1980 building Labor/Delivery Decontamination room containing greater than 32 gal. of soiled linen/waste materials was observed to have a corridor door which did not close to a latched condition to comply with 8.4.1.2, 8.2.4 and 19.3.6.3.2.

06/28/12 - the above door does not latch

C. Corrected 06/28/12

D. The Ground floor Emergency Room Soiled Utility room door was observed to have a door which did not close to a latched condition to comply with 8.4.1.2, 8.2.4 and 19.3.6.3.2.

06/28/12 - the above door does not latch

End

Based on random observation during the survey walk-through on 10/12/11, Laboratories employing quantities of flammable, combustible materials are not protected in accordance with 19.3.2.1. These deficiencies could affect all patients on the 1st floor of the facility, as well as any staff and visitors present, by exposing the facility to fire and smoke in the event of ignition.

Findings include:

A. The Lab suite corridor door from the Lobby was not self-closing to a latched condition in compliance with 19.3.2.1.

The above item was corrected on 06/28/12; however, the referenced door has a magnetic hold open device but lacks a local smoke detector to release the hold open device in accordance with 7.2.1.8.

End

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K038 New

A) (New 6/28/12) The surveyor finds that means of egress are not installed and maintained to provide a comply protected path to the outside in accordance with Chapter 7 of NFPA 101 - 2000.

The surveyor finds that the provider brings in a Mobile PET/CT Unit once a week and parks it in the Clean Loading Dock. The unit is used strictly for outpatient diagnostics. Because of its proximity to the Hospital, less than 5'-0" it has been evaluated as part of the Hospital; however it does not constitute a fire hazard to the Hospital. This mobile unit has been evaluated as a Business Occupancy under Chapter 39 of NFPA 101 and it does not comply.

1) The Mobile unit has an exit door to the outside the is marked with an exit sign. This door was rough 48" above the pavement. Comply steps with a landing and railings was not provided. The exit door was not usable as an exit.

2) The only other means of egress was through a rolling shutter that is installed next to the exit door. However, this rolling shutter does not comply with 7.2.1.4.1 c).

The unit has not complying means of egress

B) Patient movement in and out of the mobile unit is through a interior space that is the breakdown and holding space for the Clean Loading Dock. This space is a hazardous area. An exit path through it and a path to provide patient access through this space is not permitted 7.5.2.1.

Based on the above, patients do not have any exits in a fire emergency.

End


13755


Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all exit or exit access doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, required to utilize the doors by preventing those occupants from reaching an exit from the building.

Findings include:

A. Doors equipped with magnetic locking devices do not comply with all requirements of 19.2.2.2.4 and 7.2.1.6. Conditions and locations observed:

1. Corrected 06/28/12

2. Corrected 06/28/12

3. Corrected 06/28/12

4. Corrected 06/28/12

5. The doors equipped with delayed egress
function are not provided with signage in
accordance with 7.2.1.6.1(d) to indicate
that the doors will release within a
specified time delay. A letter from
IDPH granting approval to delete the
signage was not otherwise available.

06/28/12: some locations cited above
were corrected. The stair door in the
emergency department has a magnetic
locking device with delayed egress. The
door lacks a sign in accordance with
7.2.1.6.1 (d).

B. Corrected 06/28/12

C. Corrected 06/28/12

D. Corrected 06/28/12

E. Corrected 06/28/12

F. Corrected 06/28/12

G. Corrected 06/28/12; however the PoC indicates that the level of exit discharge is the 1st Floor instead of the Lobby Level!

The PoC includes a corrective action for a Lobby Level smoke barrier. This corrective action is not relevent to K38 and/or the stair cited. See K025.

End

.

Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all occupants of the fire compartments on either side of the fire barrier because the deficiencies could permit fire and smoke to pass between fire compartments.

Findings include:

A. Corrected 06/28/12

B. Fire barrier doors did not close to a latched condition when opened after initial closing. It was observed that a light pressure on the panic device could open the doors but not reset to allow the doors to latch upon closing. Locations observed to exhibit this condition included but are not necessarily limited to:

1. The 3rd floor fire barrier doors north of the 1980 building three-elevator lobby did not close to latch on 06/28/12 due to air pressure differential.

2. Corrected 06/28/12

End
.

Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all exit discharge locations are provided with illumination to comply with 38.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

A. The exit discharge lighting provided at the east exit was not provided in accordance with 7.8.1.4. The fixture provided was of the single HID lamp type. Surveyor notes that lighting on an emergency power supply is not required per the requirements of 38.2.9.1.

06/28/12: The surveyor finds that the above item was corrected: however, the paved path to a public way from the designated exit door is obstructed by a dumpster.

End

K046 New

A) (New 6/28/12) The surveyor finds that emergency lighting is not installed and maintained in accordance 7.9.3 of NFPA 101 - 2000.

The surveyor finds that the provider brings in a Mobile PET/CT Unit once a week and parks it in the Clean Loading Dock. The unit is used strictly for outpatient diagnostics. Because of its proximity to the Hospital, less than 5'-0", it has been evaluated as part of the Hospital; however it does not constitute a fire hazard to the Hospital. This mobile unit has been evaluated as a Business Occupancy under Chapter 39 of NFPA 101 and it does not comply.

1) The Mobile Unit has emergency lighting fixtures with batteries. The Mobile Unit and/or the Hospital lacks written documentation, on site, for the testing and maintenance of these lighting fixtures in the mobile unit in accordance with 7.9.3.

End

K052 New

K046 New

A) (New 6/28/12) The surveyor finds that the Mobile Unit fire alarm system is not and maintained NFPA 72- 1999.

The surveyor finds that the provider brings in a Mobile PET/CT Unit once a week and parks it in the Clean Loading Dock. The unit is used strictly for outpatient diagnostics. Because of its proximity to the Hospital, less than 5'-0" it has been evaluated as part of the Hospital; however it does not constitute a fire hazard to the Hospital. This mobile unit has been evaluated as a Business Occupancy under Chapter 39 of NFPA 101 and it does not comply.

1) The Mobile Unit has a limited fire alarm system. The tag on the main fire alarm panel for the unit indicates that it was last tested in March of 2011. No documentation of testing or maintenance was available for 2012. The Mobile Unit and/or the Hospital lacks written documentation, on site, for the testing and maintenance of this fire alarm system.

Failure to test and maintain the fire alarm system could cause failure of the system during a fire.

End

A. Corrected 06/28/12

B. Corrected 06/28/12

C. Corrected 06/28/12

D. Corrected 06/28/12



14416


E. Based on direct observation 10/12/11, the facility failed to provide automatic sprinkler protection for the following areas. These deficiencies compromise the safety of all occupants and does not allow for fire suppression and alarm to the facility:

1. The basement elevator machine room for Elevator No. 5 (NFPA 13, 1999, 5-13.6). 06/28/12 - the machine room is sprinkler protected; however the tunnel like space that is open to the machine room is not sprinklered.

2. Corrected 06/28/12

3. Corrected 06/28/12

4. Corrected 06/28/12

5. Corrected 06/28/12

6. (New 6/28/12) There are two dock areas with canopies that have been sprinklered with glycol systems in accordance with NFPA 13, 1999, 5-13.8.2.

a) The Compactor Foyer near one of the Loading docks is an interior space that lacks sprinkler protection.

b) Two of two control valves for the two glycol systems lack electronic supervision in accordance with 9.7.2.1 of NFPA 101-2000.

c) The initial acceptance test documentation for two new glycol systems was not available on site in accordance with NFPA 13/NFPA 25.

End

.



17659


F. Corrected 06/28/12

G. Corrected 06/28/12

H. Corrected 06/28/12

End

A) By direct observation the facility failed to provide:

1) Identification of service openings for installed fire dampers. (NFPA 90A, 1999, 2-3.4.2)

06/28/12 - the above item did not clear because corrective actions were not shown to the surveyor.

End

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1. Corrected 06/28/12

2. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation as required by NFPA-70, Section 620-53.

06/28/12 - Elevator # 1 through 3 do not comply with the above.

3. Corrected 06/28/12

4. The surveyor did not observe and staff was unable to verify that the elevators were equipped with fire fighter's service as required by NFPA 101, Section 9.4.3.2, and ANSI A17.3, Rule 211.3.

Based on random testing on 06/28/12, the provider was unable to demonstrate compliance with A17.3:

a) Elevators # 1, 2 and 3 were tested for recall to a primary floor. Two of the elevators recalled to the Lobby Floor Level while Elevator # 2 recalled to the 1st Floor.

b) Elevator # 4 was tested for recall to the designated alternate floor. This elevator recalled to the 2nd Floor while Elevator # 6 and 7 recalled (alternate floor) to the Ground Floor.

The provider lacked specific written information designating the primary floor of elevator recall and the alternate floor of recall for each elevator, as identified from the Fire Department.

End

K021 New

A) (New 6/28/12) The 1st floor Lab suite northwest double egress door has a door closer with a hold open device that is not designed to release the door upon activation of the fire alarm system. Also, a smoke detector is not installed within five feet of the door in accordance with 7.2.1.8.

Failure to install and maintain fire doors could result in spread of fire and smoke to patient areas.

End

K025 (New)

A) From observation, the surveyor finds that the Lobby Level of the Lobby Level of the 1980 Building was very recently renovated. The specifics of this renovation are not available. However, based on the extent of renovation, the surveyors find that 18.3.7.1 (2) is applicable. The provider has not demonstrated how two smoke compartments are provided in accordance wit 18.3.7.1.

It is the intent of this citation to remove the information provided in the PoC under K038 G and to revise and resubmit the information under K025.

End

K046 New

A) (New 6/28/12) The surveyor finds that emergency lighting is not installed and maintained in accordance 7.9.3 of NFPA 101 - 2000.

The surveyor finds that the provider brings in a Mobile PET/CT Unit once a week and parks it in the Clean Loading Dock. The unit is used strictly for outpatient diagnostics. Because of its proximity to the Hospital, less than 5'-0", it has been evaluated as part of the Hospital; however it does not constitute a fire hazard to the Hospital. This mobile unit has been evaluated as a Business Occupancy under Chapter 39 of NFPA 101 and it does not comply.

1) The Mobile Unit has emergency lighting fixtures with batteries. The Mobile Unit and/or the Hospital lacks written documentation, on site, for the testing and maintenance of these lighting fixtures in the mobile unit in accordance with 7.9.3.

End

K052 New

K046 New

A) (New 6/28/12) The surveyor finds that the Mobile Unit fire alarm system is not and maintained NFPA 72- 1999.

The surveyor finds that the provider brings in a Mobile PET/CT Unit once a week and parks it in the Clean Loading Dock. The unit is used strictly for outpatient diagnostics. Because of its proximity to the Hospital, less than 5'-0" it has been evaluated as part of the Hospital; however it does not constitute a fire hazard to the Hospital. This mobile unit has been evaluated as a Business Occupancy under Chapter 39 of NFPA 101 and it does not comply.

1) The Mobile Unit has a limited fire alarm system. The tag on the main fire alarm panel for the unit indicates that it was last tested in March of 2011. No documentation of testing or maintenance was available for 2012. The Mobile Unit and/or the Hospital lacks written documentation, on site, for the testing and maintenance of this fire alarm system.

Failure to test and maintain the fire alarm system could cause failure of the system during a fire.

End