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Based on observation and interview, the Hospital failed to comply with the applicable NFPA 101, 2012 edition requirements for construction separation, specifically those outlined in Chapters 18.1.1.4.1 through 43.8. The lack of a 1-hour fire-rated barrier or active life safety systems such as fire sprinkler protection and fire alarm notification devices in the renovation zone constitutes a non-compliant condition during modification of the facility. This deficient practice affects all patients, staff, and visitors in 1 of 4 total smoke zones.

Findings Include:

On 07/31/2025 it was observed:

At 9:00 AM to 11:15 AM in the 400 Corridor, East End, active construction was taking place to renovate a portion of the corridor. The construction area was not protected by a compliant 1-hour fire-rated construction separation, and it lacked active life safety systems including fire sprinkler coverage and fire alarm devices. This condition presents a significant life safety hazard to patients, staff, and visitors within the affected smoke zone.

The Director of Plant Operations was present and acknowledged the deficiency.

Reference:
NFPA 101, 2012 edition

Chapter 18.1.1.4.1: Additions shall comply with Section 43.8, and common walls with nonconforming buildings shall have a 2-hour fire resistance rating.

Chapter 43.3 - 43.6: Applicable requirements for rehabilitation work.

Chapter 43.8: Requirements for additions including construction separations and protection of communicating openings.

Applicable CFR: §482.15 - Hospitals (Condition of Participation - Emergency Preparedness / Life Safety from Fire)