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Based on observation and interview the building fire resistive construction was not being maintained in the Mechanical Rooms.

The findings include:

On July 11, 2012 at 11:05 AM; that several small areas of less than 20 square inches of the spray on fire proofing material was missing from the fire rated building structure roof beams on the bottom flange in the first floor Mechanical Room.

On July 11, 2012 at 11:54 AM; that several small areas of less than 20 square inches of the spray on fire proofing material was missing at the fire rated building structure roof beams on the bottom flange in the 2nd floor Mechanical Room.

The Maintenance Director, interview on July 11, 2012 at 3:30 PM, agreed with the findings and he had staff to begin making repairs.

Based on observation and interview it was determined that the corridor doors to the fire rated enclosure of the Material Managing storage room was not maintaining the fire rated doors latched. This had the ability to affect 10% of the building occupants.

The Findings Include:

On July 11, 2012 at 10:55 AM, It was observed that both doors of the double fire rated doors from the Service Corridor to the Material Managing Storage room were not propely self closing and latching when released from the approved magnetic hold open device.

The Maintenance Director, interviewed on July 11, 2012,at 3:30 PM, agreed with the finding. The doors were ajusted and made to work properly before the end of the survey.

Based on observation and interviews the rated smoke barrier was not maintained. The automatic door closing device had been removed in the third floor Smoke Barrier. The delay in closing this door had the ability to affect 100% of the patients on this floor.

The Findings Include:

On July 11, 2012 at 2:49 PM, the door closure had been removed from the fire rated door to room 324 were part of the smoke barrier wall.

The Maintenance Director, interview on July 11, 2012 at 3:30 PM, agreed with the findings.

Based on observations and interview the exit doors are not being maintained readily accessable in the first floor Mechanical room. This does not affect the patients located in an non patient area

The Findings Include:

On July 11, 2012 at 11:05 AM, The exit door from the first floor Mechanical room to the exterior required more than 15 lbs. maximum force to open.

The Maintenance Director, interviewed on July 11, 2012 at 3:30 PM, agreed with the findings and the exit door was adjusted to open correctly before the survey ended.

Based On observations and interview it was determined that the fourth floor corridor was being obstructed by unattended carts. This had the ability to affect 50 of the patients on the fourth floor.

The Findings Include:

On July 11, 2012 at 10:25 AM, several computer carts were left unattended in the corridor of the fourth floor.

The Maintenance Director, interviewed on July 11, 2012 at 3:30 PM, agreed with the findings. All unattended carts were removed from the corridor during this survey.

Based on observation, interview and review of records it was determinedthat all required fire drills were not conducted during the last 12 months. This had the ability to affect all patients.

The Findings Include:

On July 11, 2012 at 10:40 AM, it was determined that from a review of the fire drill records that documentation was not available to show that a fire drill had been conducted during the first quarter of 2012 on 2nd shift.

The Maintenance Director, interviewed on July 11, 2012 at 3:30 PM, agreed with the findings

Based on observation and interviews, it was determined that the sprinkler sytem was not maintained as approved. This has the ability to affect 10% of the patients.

The Findings Include:

On July 11, 2012 at 12:00 PM, sprinkler heads are located at less than 6 feet apart in the file room of Health Information

The Maintenance Director, interviewed on July 11, 2012 at 3: 30 PM, agreed with the findings

Based on observations, review of records and interviews it was determined that window curtains and drapes do not appear to be fire resistant nor fire retradant treated as per the requirments of NFPA 701. This has the ability to affect 10 % of the patients

The Findings Include:

On July 11, 2012 at 3:10 PM, when requested of the Materials Manager the documentation to show that the drapes in the Chapel and several other offices in the building, documentation was not available for review to asure that the drapes were fire resistant or fire retartant treated as per the requirements of NFPA 701.

The Maintenance Director, interviewed on July 11, 2012 at 3:30 PM agreed with the findings.

Based on oservation and interviews the open junction boxes were not provided with approved covers.

The Findings Include:

On July 11, 2012 at 11:49 AM an electrical 4x4 junction box was not provided with an approved cover in the #3 C.T. room.

The Maintenance Director, interviewed on July 11, 2012 at 3:30 PM, agreed with the findings and had the approved cover installed.

Based on observations and interview alcohol based hand rub dispensers were located above light switches. This has the abuilty to affect 10% of the patients.

The Findings Include:

On July 11, 2012 at 2:45 PM it was observed that alcohol based hand rub dispensers were located above the light switches in the Respiratory Offices.

The Maintenance Director, interviewed on July 11, 2012 at 3:30 PM agreed with the findings and had the ABHR dispencers removed and relocated.

Based on observation and interview the building fire resistive construction was not being maintained in the Mechanical Rooms.

The findings include:

On July 11, 2012 at 11:05 AM; that several small areas of less than 20 square inches of the spray on fire proofing material was missing from the fire rated building structure roof beams on the bottom flange in the first floor Mechanical Room.

On July 11, 2012 at 11:54 AM; that several small areas of less than 20 square inches of the spray on fire proofing material was missing at the fire rated building structure roof beams on the bottom flange in the 2nd floor Mechanical Room.

The Maintenance Director, interview on July 11, 2012 at 3:30 PM, agreed with the findings and he had staff to begin making repairs.

Based on observation and interview it was determined that the corridor doors to the fire rated enclosure of the Material Managing storage room was not maintaining the fire rated doors latched. This had the ability to affect 10% of the building occupants.

The Findings Include:

On July 11, 2012 at 10:55 AM, It was observed that both doors of the double fire rated doors from the Service Corridor to the Material Managing Storage room were not propely self closing and latching when released from the approved magnetic hold open device.

The Maintenance Director, interviewed on July 11, 2012,at 3:30 PM, agreed with the finding. The doors were ajusted and made to work properly before the end of the survey.

Based on observation and interviews the rated smoke barrier was not maintained. The automatic door closing device had been removed in the third floor Smoke Barrier. The delay in closing this door had the ability to affect 100% of the patients on this floor.

The Findings Include:

On July 11, 2012 at 2:49 PM, the door closure had been removed from the fire rated door to room 324 were part of the smoke barrier wall.

The Maintenance Director, interview on July 11, 2012 at 3:30 PM, agreed with the findings.

Based on observations and interview the exit doors are not being maintained readily accessable in the first floor Mechanical room. This does not affect the patients located in an non patient area

The Findings Include:

On July 11, 2012 at 11:05 AM, The exit door from the first floor Mechanical room to the exterior required more than 15 lbs. maximum force to open.

The Maintenance Director, interviewed on July 11, 2012 at 3:30 PM, agreed with the findings and the exit door was adjusted to open correctly before the survey ended.

Based On observations and interview it was determined that the fourth floor corridor was being obstructed by unattended carts. This had the ability to affect 50 of the patients on the fourth floor.

The Findings Include:

On July 11, 2012 at 10:25 AM, several computer carts were left unattended in the corridor of the fourth floor.

The Maintenance Director, interviewed on July 11, 2012 at 3:30 PM, agreed with the findings. All unattended carts were removed from the corridor during this survey.

Based on observation, interview and review of records it was determinedthat all required fire drills were not conducted during the last 12 months. This had the ability to affect all patients.

The Findings Include:

On July 11, 2012 at 10:40 AM, it was determined that from a review of the fire drill records that documentation was not available to show that a fire drill had been conducted during the first quarter of 2012 on 2nd shift.

The Maintenance Director, interviewed on July 11, 2012 at 3:30 PM, agreed with the findings

Based on observation and interviews, it was determined that the sprinkler sytem was not maintained as approved. This has the ability to affect 10% of the patients.

The Findings Include:

On July 11, 2012 at 12:00 PM, sprinkler heads are located at less than 6 feet apart in the file room of Health Information

The Maintenance Director, interviewed on July 11, 2012 at 3: 30 PM, agreed with the findings

Based on observations, review of records and interviews it was determined that window curtains and drapes do not appear to be fire resistant nor fire retradant treated as per the requirments of NFPA 701. This has the ability to affect 10 % of the patients

The Findings Include:

On July 11, 2012 at 3:10 PM, when requested of the Materials Manager the documentation to show that the drapes in the Chapel and several other offices in the building, documentation was not available for review to asure that the drapes were fire resistant or fire retartant treated as per the requirements of NFPA 701.

The Maintenance Director, interviewed on July 11, 2012 at 3:30 PM agreed with the findings.

Based on oservation and interviews the open junction boxes were not provided with approved covers.

The Findings Include:

On July 11, 2012 at 11:49 AM an electrical 4x4 junction box was not provided with an approved cover in the #3 C.T. room.

The Maintenance Director, interviewed on July 11, 2012 at 3:30 PM, agreed with the findings and had the approved cover installed.