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The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 and as required by the LSC

On 09/17/14 at 10:30 AM and at times throughout the day, the surveyor along with the Engineering Technician and the Vice President of Human Resources & Support Services that the smoke barrier walls throughout the facility above the suspended ceiling assembly for the corridor smoke doors and adjacent smoke barriers walls had voids and penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a half hour fire resistance rating as required and the building separation wall leaving the Periop building had voids and penetrations that were not sealed with materials having at least a two hour fire resistance rating as require

The facility did not assure that the required automatic sprinkler system was electronic interconnected to the facility fire alarm system as required by the referenced LSC.

On 09/17/14 at 11:17 AM and times throughout the day, the surveyor along with the Vice President of Human Resources & Support Services and the Director of Facilities and Engineering observed that the two (2) ¼ turn control valves on the foam bladder for the helipad foam suppression system were not supervised by the fire alarm system and the antifreeze loop serving the main kitchen walk-in coolers and freezers had two (2) ¼ turn valves that also were not supervised by the fire alarm system.

The facility did not ensure that the facilities air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems and NFPA 72 National Fire Alarm Code as required by the referenced LSC.

On 09/17/14 at 10:00 AM, the surveyor was not provided with documentation by the Vice President of Human Resources & Support Services and the Director of Facilities and Engineering that the smoke dampers were tested annually as required in NFPA 90A 3-4.7 & NFPA 72 National Fire Alarm Code.

The facility did not ensure that linen and trash chutes, incinerators and trash collection rooms were protected as required by the referenced LSC.

On 09/17/14 at 10:38 AM and times throughout the day the surveyor along with the Vice President of Human Resources & Support Services and the Director of Facilities and Engineering observed that the linen chute doors in building 1 floors level H and G failed to close and latch properly after it was released in order to provide the proper vertical fire and smoke protection between floors.

1. The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110 " Standard for Emergency and Standby Power Systems " .

On 09/17/14, the surveyor was not provided with documentation by the Director of Facilities and Engineering that the facilities emergency generator was being maintained as required by NFPA 110 " Standard for Emergency and Standby Power Systems " and/or manufacturers recommendations i.e. no Level 1 service on an annual basis for the 750 KW generator serving the Perioperative Building " last service 07/12/14 " and " prior service was 03/15/12 " a period of almost two a half years. The service slips from 05/30/14 indicated many items needing attention for all the other two generators serving the hospital and the items had not been repaired by the day of survey.

2. The facility did not ensure that electrical receptacle outlets in patient areas were maintained as required in NFPA 99 " Health Care Facilities " Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program..

On 09/17/14, the surveyor was not provided with documentation by the Director of Facilities and Engineering that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3. , and as part of the facilities preventive maintenance program and if the hospital grade exception was being utilized that it was based on documented performance data and what the plan for testing was by policy.

The facility did not ensure that electrical receptacle outlets in patient areas were maintained as required in NFPA 99 " Health Care Facilities " Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program..

On 09/17/14, the surveyor was not provided with documentation by the Director of Facilities and Engineering that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3. , and as part of the facilities preventive maintenance program and if the hospital grade exception was being utilized that it was based on documented performance data and what the plan for testing was by policy.

The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 and as required by the LSC

On 09/17/14 at 10:30 AM and at times throughout the day, the surveyor along with the Engineering Technician and the Vice President of Human Resources & Support Services that the smoke barrier walls throughout the facility above the suspended ceiling assembly for the corridor smoke doors and adjacent smoke barriers walls had voids and penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a half hour fire resistance rating as required and the building separation wall leaving the Periop building had voids and penetrations that were not sealed with materials having at least a two hour fire resistance rating as require

The facility did not assure that the required automatic sprinkler system was electronic interconnected to the facility fire alarm system as required by the referenced LSC.

On 09/17/14 at 11:17 AM and times throughout the day, the surveyor along with the Vice President of Human Resources & Support Services and the Director of Facilities and Engineering observed that the two (2) ¼ turn control valves on the foam bladder for the helipad foam suppression system were not supervised by the fire alarm system and the antifreeze loop serving the main kitchen walk-in coolers and freezers had two (2) ¼ turn valves that also were not supervised by the fire alarm system.

The facility did not ensure that the facilities air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems and NFPA 72 National Fire Alarm Code as required by the referenced LSC.

On 09/17/14 at 10:00 AM, the surveyor was not provided with documentation by the Vice President of Human Resources & Support Services and the Director of Facilities and Engineering that the smoke dampers were tested annually as required in NFPA 90A 3-4.7 & NFPA 72 National Fire Alarm Code.

The facility did not ensure that linen and trash chutes, incinerators and trash collection rooms were protected as required by the referenced LSC.

On 09/17/14 at 10:38 AM and times throughout the day the surveyor along with the Vice President of Human Resources & Support Services and the Director of Facilities and Engineering observed that the linen chute doors in building 1 floors level H and G failed to close and latch properly after it was released in order to provide the proper vertical fire and smoke protection between floors.

1. The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110 " Standard for Emergency and Standby Power Systems " .

On 09/17/14, the surveyor was not provided with documentation by the Director of Facilities and Engineering that the facilities emergency generator was being maintained as required by NFPA 110 " Standard for Emergency and Standby Power Systems " and/or manufacturers recommendations i.e. no Level 1 service on an annual basis for the 750 KW generator serving the Perioperative Building " last service 07/12/14 " and " prior service was 03/15/12 " a period of almost two a half years. The service slips from 05/30/14 indicated many items needing attention for all the other two generators serving the hospital and the items had not been repaired by the day of survey.

2. The facility did not ensure that electrical receptacle outlets in patient areas were maintained as required in NFPA 99 " Health Care Facilities " Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program..

On 09/17/14, the surveyor was not provided with documentation by the Director of Facilities and Engineering that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3. , and as part of the facilities preventive maintenance program and if the hospital grade exception was being utilized that it was based on documented performance data and what the plan for testing was by policy.

The facility did not ensure that electrical receptacle outlets in patient areas were maintained as required in NFPA 99 " Health Care Facilities " Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program..

On 09/17/14, the surveyor was not provided with documentation by the Director of Facilities and Engineering that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3. , and as part of the facilities preventive maintenance program and if the hospital grade exception was being utilized that it was based on documented performance data and what the plan for testing was by policy.