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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. Corrected 10/7/10.
b. Corrected 10/7/10.
2. Third Floor: Corrected 10/7/10.

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.

UPDATE 10/7/10: The PoC dated 7/30/10 for the 1/20/10 follow-up survey indicated that "The Atrium and the remainder of the building are currently being evaluated for compliance with the requirements of 8.2.5.5, 8.2.5.6 or IBC 404." At the time of the 10/7/10 follow-up survey it was still not clear how the space was in compliance. The following conditions were noted:

a. The plenum ceiling "portholes" utilized as transfer openings through the enclosing walls of the atrium space were equipped with fire dampers only. These openings did not have smoke dampers or fire/smoke dampers to allow the walls to qualify as being constructed as a corridor wall to meet the requirements of 8.2.5.6(1) as an Atrium. Fire dampers do not limit the transfer of smoke through the wall.

b. The space was not otherwise indicated to be reviewed or otherwise verified to be in compliance with the requirements of 8.2.5.5.

UPDATE 5/24/11: The PoC dated 1/20/11 indicated that completion would be 5/1/11. This date has not been met. The current condition remains with electrical having been complete, however damper installation and fire alarm connection remains incomplete. 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. It is the understanding of this writer that a total of 21 dampers are to be installed. This work has not begun at the time of the 5/24/11 Follow up visit.

UPDATE 7/16/11: The PoC dated 6/6/11 indicated that smoke dampers would be installed on all 21 supply air "portholes" (on the first and third floors) and be interconnected with the MOB fire alarm system so that the dampers will close at once if smoke is detected in any of the ductwork throughout the building. It is not clear how the Atrium space complies with NFPA 101-2000, 8.2.5.6 as an Atrium relative to a smoke control/evacuation/management system installed in accordance with NFPA 92A and/or 92B. The following was observed:

a. Smoke dampers are installed at the enclosing walls of the Atrium on the ducted supply air grilles of the ventilation system. The return grilles penetrate the walls to enter an above ceiling space return plenum. The return air system appears to be used as the smoke evacuation system for the entire building including the Atrium space. A complete and clear understanding of how the system is designed to operate is needed.

b. The supply air duct on the 3rd floor near the open stair was equipped with a smoke damper at the wall above the stair rather than at the trunk line duct at the enclosing wall of the Atrium. It was not confirmed how this installation met the requirements for the placement of smoke dampers in the enclosing walls of the Atrium space.

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:


(UPDATE 5/24/11) Due to the outstanding K-Tag item in building # 5 which is directly connected to the hospital - this Tag shall remain open.
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.


16339


B. Corrected 1/20/10


26665


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. Corrected 10/7/10
2. Corrected 10/7/10