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A) (Corrected 10/22/12

B) Multiple fire doors or smoke doors are held open with magnetic hold open devices but lack smoke detection installed within five feet of the door on one or both sides in accordance with 7.2.1.8.

1) (Lobby Level) Pair of fire doors to the Gift Shop Storage Room

2) (Lobby Level) Pair of designated smoke doors near the Coding Office

3) (Lobby Level) Pair of fire doors south of the Lobby Elevators

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

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. Corrected 10/22/12


C. Corrected 06/28/12

D. Corrected 10/22/12

E (New 10/22/12): The south wall of the Gift Shop Storage Room is a designated one hour fire barrier. Multiple penetrations from both sides, above the ceilings are not sealed for one hour construction. A vertical strip was left bare of drywall on the storage room side of the wall.

End

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.

10/22/12: The surveyor will need to see the steps used or a photograph. The Mobile unit is only onsite on Thursdays.

2) Deleted 10/22/12

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.

10/22/12: The construction to resolve the above conditions is currently incomplete and does not comply with 18.3.2.1.

1) The storage/holding space has a pair of 20 minute fire rated doors instead or 3/4 hour doors.

2) These doors have magnetic hold open devices but lack local smoke detection in accordance with 7.2.1.8.

3) The are multiple holes and voids in the designated one hour barrier above the ceiling.



13755


A. Corrected 10/22/12

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 10/22/12

A. Corrected 06/28/12

B. Corrected 10/22/12

C. (New 10/22/12) The two or three hour fire barrier at the 1st Floor, east of Stair # 5, has multiple penetrations from both sides of the wall above an abandoned fire shutter that are not sealed for two hour fire rated construction.

End
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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) (Modified 10/22/12): The Mobile Unit has a limited fire alarm system. The documentation dated July 2012 indicated that the fire alarm system batteries are deficient. No documentation is available to show how this was corrected.

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. Corrected 10/22/12

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) Corrected 10/22/12

b) Corrected 10/22/12

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

10/22/12: The initial acceptance test documentation was incomplete for the two glycol systems. The chemicals used, the specific gravity and the low point temperature was not provided as part of the initial acceptance test documentation.

End

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17659


F. Corrected 06/28/12
G. Corrected 06/28/12
H. Corrected 06/28/12

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. Corrected 10/22/12

3. Corrected 06/28/12

4. The surveyor finds that staff was unable to demonstrate 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.

a) Based on random testing on 10/22/12, the provider was unable to demonstrate compliance with A17.3: 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 # 3 failed to recall at all and stayed on th 4th Floor.

b) Corrected 10/22/12