HospitalInspections.org

An on-site revisit survey was conducted on July 13, 2011, to verify corrective actions of specific allegations outlined in the deficiency list for the January 7, 2011 life safety code inspection. The following deficiency was noted on this survey.

It was observed during the on-site revisit that the facility failed to protect vertical openings in accordance with Life Safety Code 101, Section 18.3.1.1 and Section 8.2.5. This was evidenced by the following:

Unprotected vertical openings did not meet the design requirements for an atrium, as required. The findings include:

1. The main entrance lobby was open between the first and second floors to a height of approximately 40-50 feet.
2. The occupancies within the atrium space had low or ordinary hazard contents and consisted primarily of waiting areas, office type reception areas, and registration.
3. Patient sleeping and treatment areas were not open to the atrium.
4. The facility had no record of a smoke control engineering analysis as required by Life Safety Code Section 8.2.5.6 (5). An engineering analysis shall be performed that demonstrates the building is designed to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 ft (1.85 m) above the highest floor level of exit access open to the atrium for a period equal to 1.5 times the calculated egress time or 20 minutes, whichever is greater.
5. The Director of Plant Operations confirmed that an engineered smoke control system was not installed in the atrium area as required by Life Safety Code Section 8.2.5.6 (6). There were no manual controls for a smoke control system in the main entrance area that would be readily accessible to the fire department as required in Section 8.2.5.6 (6).
6. The atrium doors were marked with illuminated exit signs on the corridor side of the doors.
7. Egress through the atrium is required exits.

An on-site revisit survey was conducted on July 13, 2011, to verify corrective actions of specific allegations outlined in the deficiency list for the January 7, 2011 life safety code inspection. The following deficiency was noted on this survey.

It was observed during the on-site revisit that the facility failed to protect vertical openings in accordance with Life Safety Code 101, Section 18.3.1.1 and Section 8.2.5. This was evidenced by the following:

Unprotected vertical openings did not meet the design requirements for an atrium, as required. The findings include:

1. The main entrance lobby was open between the first and second floors to a height of approximately 40-50 feet.
2. The occupancies within the atrium space had low or ordinary hazard contents and consisted primarily of waiting areas, office type reception areas, and registration.
3. Patient sleeping and treatment areas were not open to the atrium.
4. The facility had no record of a smoke control engineering analysis as required by Life Safety Code Section 8.2.5.6 (5). An engineering analysis shall be performed that demonstrates the building is designed to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 ft (1.85 m) above the highest floor level of exit access open to the atrium for a period equal to 1.5 times the calculated egress time or 20 minutes, whichever is greater.
5. The Director of Plant Operations confirmed that an engineered smoke control system was not installed in the atrium area as required by Life Safety Code Section 8.2.5.6 (6). There were no manual controls for a smoke control system in the main entrance area that would be readily accessible to the fire department as required in Section 8.2.5.6 (6).
6. The atrium doors were marked with illuminated exit signs on the corridor side of the doors.
7. Egress through the atrium is required exits.