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Based on random observation during the survey walk-through and document review, not all portions of the building are of fire resistive construction in accordance with 38.1.6.

Findings include:

A. Contract documents for the building identify it as being of Type 1B construction as defined by the Chicago Building Code; Surveyor 14290 notes that this is equivalent to Type I (332) construction as defined by NFPA 220 1999 Table 3-1. Unprotected steel (including columns and beams supporting roofs) was observed to not be fireproofed in a manner consistent with the identified construction type for the building. Locations observed include:

1. Fifth Floor, perimeter columns and beams supporting the roof.

2 Sixth Floor, columns and beams supporting the roof.

Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

A. Portions of the steel structure were observed that are not covered by fire proofing materials in accordance with the designated UL Design. Locations observed include (all Blum Building Ninth Floor):

1. Shaft north of Exit Stair A, 2 steel columns and steel beam supporting roof.

2. Shaft south of Exit Stair A, 2 steel columns and steel beam supporting roof.

3. Corrected 1/20/10

Based on random observation during the survey walk-through and staff interview, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 38.3.1.1.

Findings include:

A. Ducts were observed that are not enclosed in fire rated shafts as required by 38.3.1.1., 8.2.5.4., and NFPA 90A 3-3.4.1. Locations observed include:

1. Fourth Floor:

a. One rectangular duct (extends from roof to Second Floor Tenant Space).

b. One round duct (extends from roof to Third Floor Tenant Space).

2. Third Floor: One rectangular duct (extends from roof to Second Floor Tenant Space).

B. The Atrium could not be verified as being in compliance with 8.2.5.6. for the reasons described below:

1. During an interview held in his Office on the afternoon of April 15, 2009, the provider's Director of Facilities was not able to verify that an engineering analysis, required by 9.2.5.6(5) had been performed with respect to the Atrium.

2. During an interview held in the Atrium on the morning of April 16, 2009, the provider's Lead Maintenance Mechanic stated that the ceiling cavity adjacent to the Atrium was a plenum space; thus the Atrium is not separated from the remainder of the building, with a minimum 1 hour fire rated enclosure, in a manner consistent with 8.2.5.6(1).


UPDATE 1/20/10: The POC dated 4/16/09 indicated that the "lead mechanic was not correct, that this is not a plenum ceiling connected to the LSMC building. The building is separated from the atrium by smoke barrier wall in compliance with 8.2.5.5(4)exception 1." In review of the corridors and the Atrium, it was noted that the corridor ceiling grills are not connected to any ductwork. The Atrium contains several "porthole" type penetrations, that appear to be utilized for return air. Based on these findings, I believe that the lead mechanic was correct and the POC was incorrect in its analysis of this space.

Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. Doors to stair shafts that are more than 4 stories in height were observed that could not be verified as carrying a minimum fire resistance rating of 1-1/2 hours as required by 8.2.3.2.3.1.(1) because the door fire rating labels were painted over. Locations observed include:

1. Blum Building Ninth Floor:

a. Door to shaft north of Exit Stair A.

b. Door to shaft north of Exit Stair A. (UPDATE: South)

UPDATE 1/20/10: These doors contain a 1 hour rated plate, they do not meet the 1 1/2 hour rating requirement.

c. Corrected 1/20/10

2. Corrected 1/20/10

B. Fire rated doors were observed at which push plates had been removed, resulting in a series of small holes which could not be verified as compromising the fire ratings for the doors required by 8.2.3.2.3.1(1). Locations observed include (all South/Center Building):

1. Exit Stair B.

2. Exit Stair E.

C. Corrected 1/20/10






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D. Corrected 1/20/10

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

A. File storage areas in non-sprinklered portions of the building were observed that are not separated from the remainder of the building by minimum 1 hour fire rated enclosures as required by 39.3.2 1. and 8.4.1.1. Locations observed include (all Blum Building):

1. File Storage Area for Suite A6600.

2. File Storage Area for Suite A6700.

B. Corrected 1/20/10
C. Corrected 1/20/10
D. Corrected 1/20/10
E. Corrected 1/20/10
F. Corrected 1/20/10







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G. Corrected 1/20/10.

Based on random observation during the survey walk-through and staff interview, not all designated suites are provided with exits in accordance with 19.2.5.2.

Findings include:

A. During an interview held in his Office on the morning of April 13, 2009, the provider's Director of Facilities stated that the South Addition/Blum Building Second Floor was divided into 2 separate suites. These suites were determined to not comply with 19.2. as described:

1. The North ICU suite was determined to have an area in excess of 5,000 square feet as prohibited by 19.2.5.6.

2. The travel distance from the most remote point of the suites to an exit access door was determined to exceed 100 feet as prohibited by 19.2.6.2.4. This condition was determined to exist at:

a. The North ICU Suite.

b. The South ICU Suite.

UPDATE 1/20/10: The facility has not provided an FSES for this K-tag, therefore it could not be verified for compliance.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. During a test of the building fire alarm system conducted on the morning of April 16, 2009, fire rated doors were observe that did not close to latch. Doors observed include (all Second Floor 4 hour fire barrier between the Blum and South/Center Buildings):

1. Pair of doors at south side of Vestibule B211.

2. Pair of doors at north side of Vestibule B211.






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B. Corrected 1/20/10

C. 3 South - Third Floor: Penetrations such as a sprinkler pipe and cable wirings were observed that are not fire sealed in the designated 4 - hour fire rated Chicago Vestibule.

D. Corrected 1/20/10
E. Corrected 1/20/10
F. Corrected 1/20/10
G. Corrected 1/20/10

Based on random observation during the survey walk-through and document review, and staff interview, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. Corrected 1/20/10
B. Corrected 1/20/10

C. An exit sign was observed, at South Addition First Floor (Emergency Department) Corridor A110, which directs building occupants into a suite as prohibited by 7.10.





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D. Corrected 1/20/10

E. The surveyor finds that the designated exit access corridors lack a secondary means of exiting to direct occupants to the nearest exit. Locations observed include:

1. First Floor "D" Bank Elevator Lobby.
2. Corrected 1/20/10

C. Corrected 1/20/10

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. Signs at exit stairs were observed that read "STAIR" and not "EXIT" as required by 7.10.1.3. This condition was observed throughout the building:

1. At all building stories, including the Penthouse and the Basement.

2. At both exit stairs at each building story.

Based on staff interview and random observation during the survey walk-through and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. Corrected 1/20/10

B. Corrected 1/20/10
.

2. Corrected 1/20/10






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C. Based upon random observation and document review the surveyors find that the provider lacks detailed Life Safety Master Plans that define the locations of suites of rooms and exit access corridors that serve suites. The surveyors find several locations where patient treatment areas appear to be opened to exit access corridors. Also corridors are obstructed with equipment where suite locations could not be confirmed.

The master plans do not identify suites:

Locations are not identified along with the
defining limits and area.

The perimeter walls for suites and corridor
doors with positive latching hardware for
suites are not identified.

Two remote exit access paths from suites
cannot be confirmed. Travel distances
within suites cannot be confirmed.

Example: First Floor: E.R. Department, Intervention Radiology Area and Ground Floor : Linear Accelerator Unit.

Based on random observation during the survey walk-through (and staff interview), not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

Findings include:

A. Corrected 1/20/10
B. Corrected 1/20/10





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C. Sprinkler escutcheon plates are missing in the following locations:

1. Fifth Floor - 5NW G.I. Lab Scope Room.
UPDATE 1/20/10: The escutcheon ring was installed but the sprinkler is located in a corner between the wall and duct access soffit. The sprinkler is within 2" of the wall / soffit not meeting the requirements of NFPA 13 1999 5-6.3.3.

2. Corrected 1/20/10
3. Corrected 1/20/10
4. Corrected 1/20/10
5. Corrected 1/20/10

D. Corrected 1/20/10


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E. Corrected 1/20/10
F. Corrected 1/20/10

Based on random observation during the survey walk-through, not all linen or refuse chutes are constructed an maintained as fire resistive assemblies.

Findings include:

A. Linen and refuse chute service doors were observed which are open to Corridors and not located within Chute Service Rooms which carry the same fire resistance rating as the chutes they serve as required by NFPA 82 1999 3-2.4.3. Locations observed include:

1. Blum Building west chute:

a. Sixth Floor.

b. Fourth Floor.

c. Third Floor.

2. South/Center Building:

a. Eighth Floor.

b. Sixth Floor.

c. Fifth Floor.




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B. The linen chute on Eighth Floor was observed to be vented by a 4" round duct and not full diameter through the roof as required by NFPA 82 1999 3-2.2.4.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. Carts and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.2. Locations and items observed include:

1. Corrected 1/20/10
2. Corrected 1/20/10
3. Corrected 1/20/10






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B. Corrected 1/20/10
C. Corrected 1/20/10

Surveyor: 12798
D. On 1/20/10, 2nd floor ICU to Surgery corridor, 2 beds were located in this exit corridor as observed during the onsite walk through.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 7.1.

Findings include:

A. Corrected 1/20/10

UPDATE 1/20/10:
B. 5th Floor, South Stair. Cleaning supplies, boxes, trash container and supply carts are being stored in the stairwell.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.





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B. Corrected 1/20/10



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C. Corrected 1/20/10
D. Corrected 1/20/10

Surveyor 12798:
E. During the onsite visit 1/20/10, it was noted that several areas have changed function and/or currently in the process of being remodeled without notification to this Department. Areas identified include, but are not limited to the following:

1. South/Center Building , 2nd floor: This area was originally the Anesthesia Work Room B243 and Storage Room B255. These are now being utilized as the "Surgeon Lounge", this remodeling did not include providing sprinkler protection for this area. It could not be determined under this Federal Survey if the surgery area currently meets with the Hospital Licensing Requirements.

2. 1st Floor - Suite C 1500 Oncology Exam Room C-146, this room is currently being remodeled into an office space.

Based on random observation during the survey walk-through and document review, not all portions of the building are of fire resistive construction in accordance with 38.1.6.

Findings include:

A. Contract documents for the building identify it as being of Type 1B construction as defined by the Chicago Building Code; Surveyor 14290 notes that this is equivalent to Type I (332) construction as defined by NFPA 220 1999 Table 3-1. Unprotected steel (including columns and beams supporting roofs) was observed to not be fireproofed in a manner consistent with the identified construction type for the building. Locations observed include:

1. Fifth Floor, perimeter columns and beams supporting the roof.

2 Sixth Floor, columns and beams supporting the roof.

Based on random observation during the survey walk-through and staff interview, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 38.3.1.1.

Findings include:

A. Ducts were observed that are not enclosed in fire rated shafts as required by 38.3.1.1., 8.2.5.4., and NFPA 90A 3-3.4.1. Locations observed include:

1. Fourth Floor:

a. One rectangular duct (extends from roof to Second Floor Tenant Space).

b. One round duct (extends from roof to Third Floor Tenant Space).

2. Third Floor: One rectangular duct (extends from roof to Second Floor Tenant Space).

B. The Atrium could not be verified as being in compliance with 8.2.5.6. for the reasons described below:

1. During an interview held in his Office on the afternoon of April 15, 2009, the provider's Director of Facilities was not able to verify that an engineering analysis, required by 9.2.5.6(5) had been performed with respect to the Atrium.

2. During an interview held in the Atrium on the morning of April 16, 2009, the provider's Lead Maintenance Mechanic stated that the ceiling cavity adjacent to the Atrium was a plenum space; thus the Atrium is not separated from the remainder of the building, with a minimum 1 hour fire rated enclosure, in a manner consistent with 8.2.5.6(1).


UPDATE 1/20/10: The POC dated 4/16/09 indicated that the "lead mechanic was not correct, that this is not a plenum ceiling connected to the LSMC building. The building is separated from the atrium by smoke barrier wall in compliance with 8.2.5.5(4)exception 1." In review of the corridors and the Atrium, it was noted that the corridor ceiling grills are not connected to any ductwork. The Atrium contains several "porthole" type penetrations, that appear to be utilized for return air. Based on these findings, I believe that the lead mechanic was correct and the POC was incorrect in its analysis of this space.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

A. File storage areas in non-sprinklered portions of the building were observed that are not separated from the remainder of the building by minimum 1 hour fire rated enclosures as required by 39.3.2 1. and 8.4.1.1. Locations observed include (all Blum Building):

1. File Storage Area for Suite A6600.

2. File Storage Area for Suite A6700.

B. Corrected 1/20/10
C. Corrected 1/20/10
D. Corrected 1/20/10
E. Corrected 1/20/10
F. Corrected 1/20/10







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G. Corrected 1/20/10.

Based on random observation during the survey walk-through and staff interview, not all designated suites are provided with exits in accordance with 19.2.5.2.

Findings include:

A. During an interview held in his Office on the morning of April 13, 2009, the provider's Director of Facilities stated that the South Addition/Blum Building Second Floor was divided into 2 separate suites. These suites were determined to not comply with 19.2. as described:

1. The North ICU suite was determined to have an area in excess of 5,000 square feet as prohibited by 19.2.5.6.

2. The travel distance from the most remote point of the suites to an exit access door was determined to exceed 100 feet as prohibited by 19.2.6.2.4. This condition was determined to exist at:

a. The North ICU Suite.

b. The South ICU Suite.

UPDATE 1/20/10: The facility has not provided an FSES for this K-tag, therefore it could not be verified for compliance.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. During a test of the building fire alarm system conducted on the morning of April 16, 2009, fire rated doors were observe that did not close to latch. Doors observed include (all Second Floor 4 hour fire barrier between the Blum and South/Center Buildings):

1. Pair of doors at south side of Vestibule B211.

2. Pair of doors at north side of Vestibule B211.






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B. Corrected 1/20/10

C. 3 South - Third Floor: Penetrations such as a sprinkler pipe and cable wirings were observed that are not fire sealed in the designated 4 - hour fire rated Chicago Vestibule.

D. Corrected 1/20/10
E. Corrected 1/20/10
F. Corrected 1/20/10
G. Corrected 1/20/10

Based on random observation during the survey walk-through and document review, and staff interview, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. Corrected 1/20/10
B. Corrected 1/20/10

C. An exit sign was observed, at South Addition First Floor (Emergency Department) Corridor A110, which directs building occupants into a suite as prohibited by 7.10.





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D. Corrected 1/20/10

E. The surveyor finds that the designated exit access corridors lack a secondary means of exiting to direct occupants to the nearest exit. Locations observed include:

1. First Floor "D" Bank Elevator Lobby.
2. Corrected 1/20/10

C. Corrected 1/20/10

Based on staff interview and random observation during the survey walk-through and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. Corrected 1/20/10

B. Corrected 1/20/10
.

2. Corrected 1/20/10






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C. Based upon random observation and document review the surveyors find that the provider lacks detailed Life Safety Master Plans that define the locations of suites of rooms and exit access corridors that serve suites. The surveyors find several locations where patient treatment areas appear to be opened to exit access corridors. Also corridors are obstructed with equipment where suite locations could not be confirmed.

The master plans do not identify suites:

Locations are not identified along with the
defining limits and area.

The perimeter walls for suites and corridor
doors with positive latching hardware for
suites are not identified.

Two remote exit access paths from suites
cannot be confirmed. Travel distances
within suites cannot be confirmed.

Example: First Floor: E.R. Department, Intervention Radiology Area and Ground Floor : Linear Accelerator Unit.

Based on random observation during the survey walk-through (and staff interview), not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

Findings include:

A. Corrected 1/20/10
B. Corrected 1/20/10





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C. Sprinkler escutcheon plates are missing in the following locations:

1. Fifth Floor - 5NW G.I. Lab Scope Room.
UPDATE 1/20/10: The escutcheon ring was installed but the sprinkler is located in a corner between the wall and duct access soffit. The sprinkler is within 2" of the wall / soffit not meeting the requirements of NFPA 13 1999 5-6.3.3.

2. Corrected 1/20/10
3. Corrected 1/20/10
4. Corrected 1/20/10
5. Corrected 1/20/10

D. Corrected 1/20/10


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E. Corrected 1/20/10
F. Corrected 1/20/10

Based on random observation during the survey walk-through, not all linen or refuse chutes are constructed an maintained as fire resistive assemblies.

Findings include:

A. Linen and refuse chute service doors were observed which are open to Corridors and not located within Chute Service Rooms which carry the same fire resistance rating as the chutes they serve as required by NFPA 82 1999 3-2.4.3. Locations observed include:

1. Blum Building west chute:

a. Sixth Floor.

b. Fourth Floor.

c. Third Floor.

2. South/Center Building:

a. Eighth Floor.

b. Sixth Floor.

c. Fifth Floor.




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B. The linen chute on Eighth Floor was observed to be vented by a 4" round duct and not full diameter through the roof as required by NFPA 82 1999 3-2.2.4.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. Carts and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.2. Locations and items observed include:

1. Corrected 1/20/10
2. Corrected 1/20/10
3. Corrected 1/20/10






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B. Corrected 1/20/10
C. Corrected 1/20/10

Surveyor: 12798
D. On 1/20/10, 2nd floor ICU to Surgery corridor, 2 beds were located in this exit corridor as observed during the onsite walk through.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.





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B. Corrected 1/20/10



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C. Corrected 1/20/10
D. Corrected 1/20/10

Surveyor 12798:
E. During the onsite visit 1/20/10, it was noted that several areas have changed function and/or currently in the process of being remodeled without notification to this Department. Areas identified include, but are not limited to the following:

1. South/Center Building , 2nd floor: This area was originally the Anesthesia Work Room B243 and Storage Room B255. These are now being utilized as the "Surgeon Lounge", this remodeling did not include providing sprinkler protection for this area. It could not be determined under this Federal Survey if the surgery area currently meets with the Hospital Licensing Requirements.

2. 1st Floor - Suite C 1500 Oncology Exam Room C-146, this room is currently being remodeled into an office space.