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A. During review of the interior finish policy, it was not clear how the responsible person in Materials Management determined the requirements for judging compliance. Although compliance with the Life Safety Code was stated, it was not specific to state the actual requirements by reference to Code sections or finish ratings.

A. Use spaces are not separated from exit access corridors to comply with 19.3.6.1 or otherwise in compliance with the exceptions permitted. Conditions observed include:

1. The sprinklered main lobby waiting area north of the elevators is indicated to not be provided with continuous direct supervision. The area is not otherwise provided with smoke detection to comply with 19.3.6.1, Exception No. 2.

2. The sprinklered EMS station at the ER exit access corridor vestibule was unattended at the time of the survey and was not provided with continuous direct supervision. The space was not otherwise provided with smoke detection to comply with 19.3.6.1, Exception No. 1.

A. Exit access corridor doors are not provided with positive latching hardware to comply with 38.3.6.1 and 8.2.3. The following conditions were observed:

1. The 3rd floor physicians office in the northwest corner of the MOB has a corridor door equipped only with a manual dead bolt lock which does not provide postive self-latching for the door. The dead bolt lock does not comply with 7.2.1.5.4 if additional latching hardware is added to door.

A. Vertical openings between floors are not protected in accordance with 8.2.3.2.4.2. Location observed include:

1. The 1st floor Tech closet #2 contained two large PVC conduits through the floor which were not sealed and/or protected in accordance with 2-hour rated construction of the floor.

2. The Tech closet in the corridor leading to the OR suite contained conduit through the floor which was not sealed in accordance with the 2-hour rated floor construction.

A. The location of the smoke barrier walls on the 1st floor level could not be determined from the available Life Safety Reference Plans provided to confirm compliance with 19.3.7.

A. Hazardous areas are not sepparated from other use areas in accordance with 19.3.2.1. Conditions observed include:

1. The 3rd floor Classroom Storage room door latch bolt sticks to prevent the door from latching when closed.

2. The 2nd floor north wing shower room is no longer equipped for such use due to plumbing changes. The room is not sprinkler protected and is utilized for linen storage without a minimum 1-hour enclosure including a minimum 3/4-hour fire rated door assembly.

A. The stair enclosure which discharges to the ER/Outpatient entry Lobby was observed to contain glass block window panels at the former exterior wall now contained within the building by the newer ER additon. It was not clear how the minimum 1-hour fire rated enclosure of this stair serving three floor levels was maintained to comply with 7.1.3.2.1.

B. The 2nd floor south stair door latch was not positive latching to comply with 7.1.3.2.1 and 8.2.3.2.1 due to the latch bolt sticking.

C. The south stair door of the 1960 building on the 1st floor level was not positive latching to comply with 7.1.3.2.1 and 8.2.3.2.1.

D. The south stair of the 1960 building contained a wooden ramp stored in the stair in non-compliance with 7.1.3.2.1.

A. Exit components are not constructed in accordance with 7.2. The following conditions were observed:

1. The 1st floor corridor leading to the 1960 building is a ramp which does not have handrails to comply with 7.2.5.4.

2. The 1st floor ramp within the 1960 building does not have handrails to comply with 7.2.5.4.

3. The 1st floor ramp outside the Generator room in the 1960 building is not provided with handrails on both sides to comply with 7.2.5.4.

4. The 3rd floor ramp accessing/exiting from the rooftop helipad is not provided with handrails and guardrails to comply with 7.2.5.4.

A. The exit discharge for the east stair of the MOB discharges to the interior of the building but compliance with 7.7.2 does not appear to be met based upon the following observed conditions:

1. The discharge path which leads thru the Lobby area contaning the elevators is provided with sprinkler protection, but is not separated from areas not sprinklered by 2-hour rated construction to comply with 7.7.2(2). The door and sidelight assembly at the Perry Home Medical wall is not minimum 1 1/2-hour rated construction due to the use of wire glass in the sidelight which exceeds the maximum 100 square inch limitation. The door was not verified to be 1 1/2-hour rated.

2. The other designated available path from the stair discharge through the corridor to the south beyond the cross corridor doors leading to the patio area exit door was not fully sprinkler protected to comply with 7.7.2(2).

B. Doors are provided with dead bolt locks that do not comply with 7.2.1.5.4 when both hardware for providing positive latching and dead bolts for locking are installed. Locations observed include but may not necessarily be limited to the following:

1. Multiple corridor doors at the 3rd floor north wing.

2. Lower level Dry Goods Storage room corridor door.

3. 1st/Ground floor 1960 buiding sprinkler room door.

C. Vertical rolling grilles at the Lower level Serving line area do not comply with 19.2.2.2.1. The surveyor notes that the Gift Shop vertical rolling grille is deemed to comply with 7.2.1.4.1, Exception No. 4 when considered under 39.2.2.2.6 as a Business use area with an occupant load not exceeding 10. The following conditions were observed at the Serving Line vertical rolling grille:

1. The occupant load of the serving line area appeared to exceed 10 and therefore could not comply under 7.2.1.4.1, Exception No. 4 when reviewed as a Business occupancy use area under 39.2.2.2.6.

2. The door locations were not provided with signage to comply with 7.2.1.4.1, Exception No. 2, (b) when reviewed as an Assembly, Business or Mercantile occupancy use area under 13/39/37.2.2.2.6.

3. The door through the Kitchen was not otherwise an available exit path due to the use of a dead bolt lock.

A. Exit discharge lighting in compliance with 19.2.8 and 7.8 could not be confirmed. Locations observed include:

1. The west exit discharge of the MOB.

2. The north exit discharge of the 1960 building.

3. The east patio exit discharge between the MOB and the Main Hospital building.

A. Exit signage did not clearly define required exit paths in accordance with 19.2.10.1 and 7.10. Conditions observed include:

1. The 4th floor south corridor of the MOB cross corridor doors near the east stair lacked exit signage on the west side of the doors to direct occupants thru the doors to the stair.

A. Fire drill documentation reviewed indicated that not all critiques were completed in their entirety. Not all questions were answered on each form to judge staff response and building component reaction. Actual fire alarm activations were not documented in the same way as those in which the drill response documentation was filled out.

B. Recorded fire drills for the 1st quarter 1st shift lacked sufficient variance in the times they were conducted. The drills conducted on 1/29/09, 2/27/09 & 3/16/10 were at 2:09 pm, 2:30 pm, & 2:10 pm respectively.

A. The fire alarm system did not comply with NFPA 72, 1999. Observed conditions include:

1. The Tech closet near the OR was provided with a detector immediately adjacent the air grille in non-compliance with NFPA 72, 2-2.4/2-3.5.1.

2. The EMS Storage room was provided with a detector within 3'-0" of the return air grille in non-compliance with NFPA 72, 2-2.4/2-3.5.1.

3. During testing of the fire alarm system where more than two strobes were observed within 55', they were not synchronized to comply with NFPA 72, 4-4.4.2.3. Locations observed include but are not necessarily limited to the following:

a. Corridor leading to the ORs.

b. Within the Radiology suite.

c. Within the ER suite.

4. The cross corridor doors between the elevators and the corridor leading to the OR suite are equipped with power openers that did not cease to operate under fire alarm activation to comply with 7.2.1.9.2.

A. Sprinkler systems are not maintained in compliance with NFPA 13. Conditions observed include:

1. The 1995 Penthouse is provided with sprinkler protection under the ductwork. However, sprinkler heads did not appear to be provided at the higher portion of the room to comply with NFPA 13, 1999, 5-6.4.1.

2. The Tech room at the ER suite was missing ceiling tile to allow the space to be open to the ceiling cavity which compromises the activation of the sprinkler head. The sprinkler head provided was not a minimum 4" from the wall/soffit face to comply with 5-6.3.3.

3. The location of sprinkler heads within the 1st floor Mechanical room at the north wing of the 1968 building could not be confirmed due to obstructed visibility. Review of available plans was not otherwise done at the time of the survey.

4. The Tech room #2 in the north wing of the 1st floor was missing ceiling tile to allow the space to be open to the ceiling cavity which compromises the activation of the sprinkler head. A detector was provided at the floor deck above the ceiling. The partial ceiling compromised the activation of the detector.

A. Medical gas piping observed in the Emergency Prepareness Storage room was not labeled to comply with NFPA 99, 1999, 4-3.1.2.14.

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.

A. Documentation for the weekly/monthly testing of the generator system was not clear to judge compliance with applicable requirements. The following conditions were observed:

1. The forms used to document test values lack tabulation of the load values for each phase.

2. The required minimum load to be transfered during monthly test under load was indicated to be the same for all three generators, but each generator is rated at different capacities; 200KW, 600KW, & 1200KW.

3. The forms indicate the load values to be expressed in "kiloamps" rather than "kilowatts" that may be read from the gauges on the generators. Load values are listed both as whole numbers and decimal values less than 1. It was not clear that the minimum cnnected load was being acheived.

4. The forms indicate transfer times of between 10 seconds and 17 seconds when the mazimum tranfer time is required to be within 10 seconds.

5. The run times are not documented consistantly. Some forms utilize the generator hour meter while others are listed by time-of-day.

A. Electrical systems did not appear to be in compliance with NFPA 70, 1999. The following conditions were observed:

1. The second floor Med/surg patient rooms were indicated to have all outlets on the emergency power system.

a. The arrangement did not appear to comply with NFPA 70, 517-18(a) which requires each bed location to be supplied by at least two branch circuits, one from the emergency system and one from the normal system. Alternatively, per Exception No. 3, it was not verified that the outlets were supplied from two separate transfer switches on the emergency system.

b. The outlets are labeled with panel and circuit from which they are served but are not of distinctive color to make them readily recognizable as being on the emergency power system to comply with NFPA 70, 517-33(c).

c. It was not confirmed that the emergency power system was divided into two branches; Life Safety branch and the Critical branch as required by NFPA 70, 517-31.

2. The second floor ICU patient room outlets appeared to be arranged similarly.

3. Panel directories (observed at the second floor ICU but may be typical throughout) did not appear to accurately identify the locations served by the circuits. As an example: panel directories identified locations by room numbers which were not coordinated with signage installed.

A. During review of the interior finish policy, it was not clear how the responsible person in Materials Management determined the requirements for judging compliance. Although compliance with the Life Safety Code was stated, it was not specific to state the actual requirements by reference to Code sections or finish ratings.

A. Use spaces are not separated from exit access corridors to comply with 19.3.6.1 or otherwise in compliance with the exceptions permitted. Conditions observed include:

1. The sprinklered main lobby waiting area north of the elevators is indicated to not be provided with continuous direct supervision. The area is not otherwise provided with smoke detection to comply with 19.3.6.1, Exception No. 2.

2. The sprinklered EMS station at the ER exit access corridor vestibule was unattended at the time of the survey and was not provided with continuous direct supervision. The space was not otherwise provided with smoke detection to comply with 19.3.6.1, Exception No. 1.

A. Exit access corridor doors are not provided with positive latching hardware to comply with 38.3.6.1 and 8.2.3. The following conditions were observed:

1. The 3rd floor physicians office in the northwest corner of the MOB has a corridor door equipped only with a manual dead bolt lock which does not provide postive self-latching for the door. The dead bolt lock does not comply with 7.2.1.5.4 if additional latching hardware is added to door.

A. Vertical openings between floors are not protected in accordance with 8.2.3.2.4.2. Location observed include:

1. The 1st floor Tech closet #2 contained two large PVC conduits through the floor which were not sealed and/or protected in accordance with 2-hour rated construction of the floor.

2. The Tech closet in the corridor leading to the OR suite contained conduit through the floor which was not sealed in accordance with the 2-hour rated floor construction.

A. The location of the smoke barrier walls on the 1st floor level could not be determined from the available Life Safety Reference Plans provided to confirm compliance with 19.3.7.

A. Hazardous areas are not sepparated from other use areas in accordance with 19.3.2.1. Conditions observed include:

1. The 3rd floor Classroom Storage room door latch bolt sticks to prevent the door from latching when closed.

2. The 2nd floor north wing shower room is no longer equipped for such use due to plumbing changes. The room is not sprinkler protected and is utilized for linen storage without a minimum 1-hour enclosure including a minimum 3/4-hour fire rated door assembly.

A. The stair enclosure which discharges to the ER/Outpatient entry Lobby was observed to contain glass block window panels at the former exterior wall now contained within the building by the newer ER additon. It was not clear how the minimum 1-hour fire rated enclosure of this stair serving three floor levels was maintained to comply with 7.1.3.2.1.

B. The 2nd floor south stair door latch was not positive latching to comply with 7.1.3.2.1 and 8.2.3.2.1 due to the latch bolt sticking.

C. The south stair door of the 1960 building on the 1st floor level was not positive latching to comply with 7.1.3.2.1 and 8.2.3.2.1.

D. The south stair of the 1960 building contained a wooden ramp stored in the stair in non-compliance with 7.1.3.2.1.

A. Exit components are not constructed in accordance with 7.2. The following conditions were observed:

1. The 1st floor corridor leading to the 1960 building is a ramp which does not have handrails to comply with 7.2.5.4.

2. The 1st floor ramp within the 1960 building does not have handrails to comply with 7.2.5.4.

3. The 1st floor ramp outside the Generator room in the 1960 building is not provided with handrails on both sides to comply with 7.2.5.4.

4. The 3rd floor ramp accessing/exiting from the rooftop helipad is not provided with handrails and guardrails to comply with 7.2.5.4.

A. The exit discharge for the east stair of the MOB discharges to the interior of the building but compliance with 7.7.2 does not appear to be met based upon the following observed conditions:

1. The discharge path which leads thru the Lobby area contaning the elevators is provided with sprinkler protection, but is not separated from areas not sprinklered by 2-hour rated construction to comply with 7.7.2(2). The door and sidelight assembly at the Perry Home Medical wall is not minimum 1 1/2-hour rated construction due to the use of wire glass in the sidelight which exceeds the maximum 100 square inch limitation. The door was not verified to be 1 1/2-hour rated.

2. The other designated available path from the stair discharge through the corridor to the south beyond the cross corridor doors leading to the patio area exit door was not fully sprinkler protected to comply with 7.7.2(2).

B. Doors are provided with dead bolt locks that do not comply with 7.2.1.5.4 when both hardware for providing positive latching and dead bolts for locking are installed. Locations observed include but may not necessarily be limited to the following:

1. Multiple corridor doors at the 3rd floor north wing.

2. Lower level Dry Goods Storage room corridor door.

3. 1st/Ground floor 1960 buiding sprinkler room door.

C. Vertical rolling grilles at the Lower level Serving line area do not comply with 19.2.2.2.1. The surveyor notes that the Gift Shop vertical rolling grille is deemed to comply with 7.2.1.4.1, Exception No. 4 when considered under 39.2.2.2.6 as a Business use area with an occupant load not exceeding 10. The following conditions were observed at the Serving Line vertical rolling grille:

1. The occupant load of the serving line area appeared to exceed 10 and therefore could not comply under 7.2.1.4.1, Exception No. 4 when reviewed as a Business occupancy use area under 39.2.2.2.6.

2. The door locations were not provided with signage to comply with 7.2.1.4.1, Exception No. 2, (b) when reviewed as an Assembly, Business or Mercantile occupancy use area under 13/39/37.2.2.2.6.

3. The door through the Kitchen was not otherwise an available exit path due to the use of a dead bolt lock.

A. Exit discharge lighting in compliance with 19.2.8 and 7.8 could not be confirmed. Locations observed include:

1. The west exit discharge of the MOB.

2. The north exit discharge of the 1960 building.

3. The east patio exit discharge between the MOB and the Main Hospital building.

A. Exit signage did not clearly define required exit paths in accordance with 19.2.10.1 and 7.10. Conditions observed include:

1. The 4th floor south corridor of the MOB cross corridor doors near the east stair lacked exit signage on the west side of the doors to direct occupants thru the doors to the stair.

A. Fire drill documentation reviewed indicated that not all critiques were completed in their entirety. Not all questions were answered on each form to judge staff response and building component reaction. Actual fire alarm activations were not documented in the same way as those in which the drill response documentation was filled out.

B. Recorded fire drills for the 1st quarter 1st shift lacked sufficient variance in the times they were conducted. The drills conducted on 1/29/09, 2/27/09 & 3/16/10 were at 2:09 pm, 2:30 pm, & 2:10 pm respectively.

A. The fire alarm system did not comply with NFPA 72, 1999. Observed conditions include:

1. The Tech closet near the OR was provided with a detector immediately adjacent the air grille in non-compliance with NFPA 72, 2-2.4/2-3.5.1.

2. The EMS Storage room was provided with a detector within 3'-0" of the return air grille in non-compliance with NFPA 72, 2-2.4/2-3.5.1.

3. During testing of the fire alarm system where more than two strobes were observed within 55', they were not synchronized to comply with NFPA 72, 4-4.4.2.3. Locations observed include but are not necessarily limited to the following:

a. Corridor leading to the ORs.

b. Within the Radiology suite.

c. Within the ER suite.

4. The cross corridor doors between the elevators and the corridor leading to the OR suite are equipped with power openers that did not cease to operate under fire alarm activation to comply with 7.2.1.9.2.

A. Sprinkler systems are not maintained in compliance with NFPA 13. Conditions observed include:

1. The 1995 Penthouse is provided with sprinkler protection under the ductwork. However, sprinkler heads did not appear to be provided at the higher portion of the room to comply with NFPA 13, 1999, 5-6.4.1.

2. The Tech room at the ER suite was missing ceiling tile to allow the space to be open to the ceiling cavity which compromises the activation of the sprinkler head. The sprinkler head provided was not a minimum 4" from the wall/soffit face to comply with 5-6.3.3.

3. The location of sprinkler heads within the 1st floor Mechanical room at the north wing of the 1968 building could not be confirmed due to obstructed visibility. Review of available plans was not otherwise done at the time of the survey.

4. The Tech room #2 in the north wing of the 1st floor was missing ceiling tile to allow the space to be open to the ceiling cavity which compromises the activation of the sprinkler head. A detector was provided at the floor deck above the ceiling. The partial ceiling compromised the activation of the detector.

A. Medical gas piping observed in the Emergency Prepareness Storage room was not labeled to comply with NFPA 99, 1999, 4-3.1.2.14.

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.

A. Documentation for the weekly/monthly testing of the generator system was not clear to judge compliance with applicable requirements. The following conditions were observed:

1. The forms used to document test values lack tabulation of the load values for each phase.

2. The required minimum load to be transfered during monthly test under load was indicated to be the same for all three generators, but each generator is rated at different capacities; 200KW, 600KW, & 1200KW.

3. The forms indicate the load values to be expressed in "kiloamps" rather than "kilowatts" that may be read from the gauges on the generators. Load values are listed both as whole numbers and decimal values less than 1. It was not clear that the minimum cnnected load was being acheived.

4. The forms indicate transfer times of between 10 seconds and 17 seconds when the mazimum tranfer time is required to be within 10 seconds.

5. The run times are not documented consistantly. Some forms utilize the generator hour meter while others are listed by time-of-day.

A. Electrical systems did not appear to be in compliance with NFPA 70, 1999. The following conditions were observed:

1. The second floor Med/surg patient rooms were indicated to have all outlets on the emergency power system.

a. The arrangement did not appear to comply with NFPA 70, 517-18(a) which requires each bed location to be supplied by at least two branch circuits, one from the emergency system and one from the normal system. Alternatively, per Exception No. 3, it was not verified that the outlets were supplied from two separate transfer switches on the emergency system.

b. The outlets are labeled with panel and circuit from which they are served but are not of distinctive color to make them readily recognizable as being on the emergency power system to comply with NFPA 70, 517-33(c).

c. It was not confirmed that the emergency power system was divided into two branches; Life Safety branch and the Critical branch as required by NFPA 70, 517-31.

2. The second floor ICU patient room outlets appeared to be arranged similarly.

3. Panel directories (observed at the second floor ICU but may be typical throughout) did not appear to accurately identify the locations served by the circuits. As an example: panel directories identified locations by room numbers which were not coordinated with signage installed.