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A) There are numerous locations throughout the facility where doors in exit access corridors were observed that are not equipped with a positive latching hardware to comply with 19.3.6.2. Example locations observed:

1. Corrected 04/15/2010.

2. Corrected 04/15/2010.

3. Corrected 04/15/2010.

4. Corrected 04/15/2010.


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5. Corrected 04/15/2010.

6. Corrected 04/15/2010.

7. Corrected 04/15/2010.

8. UPDATE: 04/15/2010 The corrective item remains unchanged. Room # 2521 and # 2523 Near Radiology.


B) Corrected 04/15/2010.

A). Corrected 04/15/2010

B). Corrected 04/15/2010.




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C) From random observations, the surveyors find that vertical openings are not enclosed and protected in accordance with 19.3.1.1 and NFPA 90A. There are no shafts identified on the 2009 Life Safety Code Plans. In too many locations to list, the surveyors observed shaft enclosures that were not enclosed in fire rated enclosures. General deficiencies include but are not limited to:

* Shafts are open to the ceiling cavities of adjacent spaces.

* Shafts have multiple penetrations of voids that are not sealed

* Shafts have access panels that are not fire rated and not self closing

Example locations include but are not limited to:

1. First floor Pharmacy Storage (deemed a hazardous area): The shaft located on the west wall (approximatley the center of this wall) is incomplete above the finished ceiling.

2. Corrected 04/15/2010

3. Corrected 04/15/2010


D). Access panels in ventilation and pipe shafts were observed that do not maintain the fire resistant rating for the shaft enclosure due to the apparent improper installation of the access door frame which allows for a large opening and a continuous gap surrounding the frame which does not comply with 8.2.5. Other locations noted include access panels installed with continuous wood nailers. This condition appears through out the facility. Example location observed: Fifth floor medication room with dumbwaiter

E). Corrected 04/15/2010

Surveyor: 26665

F). Patient bathrooms were observed to have recessed medicine cabinets in the exhaust duct chase with no fire rating on the medicine cabinets in accordance with 3-3.4.1. Areas include;

1. Fourth Floor.

2. Fifth floor.

3. Sixth floor.

4. Seventh floor.

5. Eighth floor.

G). The equipment room on fifth floor was observed to have ductwork exiting and penetrating the fourth floor roof at 2 locations. The west duct penetrations were observed in the sleep study area which were not enclosed in a fire rated shaft to comply with 3-3.4.1.

H). At the time of the survey it could not be verified if the east duct penetrations into the sleep study area were enclosed to comply with 3-3.4.1 due to patient occupancy.

A). Due to the lack of clearly indicated smoke barriers on all floors of the Facility provided Life Safety Plans. It appears that the travel distance from one smoke compartment to the next exceeds the allowable maximum distance. Example location observed: First floor, central part of building including Mechanical, housekeeping, shipping recieving, bed storage, cafeteria and other adjacent areas (this does not include the possible 2-hour barrier adjacent to the kitchen).

A.) Fourth Floor- Patient Service Room 4266: The surveyor finds that this former Patient Room which has been converted into a Patient Service Room is being used as an office and for storing patient's medical records which due to the amount of storage is considered a hazardous area. The door is not self-closing to comply with 19.3.2.1.

B.) Corrected 04/15/2010.

C.) Corrected 04/15/2010.




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D) Corrected 04/15/2010

A) Numerous access panels in designated exit stairs throughout the facility (stair shafts are indicated on the facility life safety drawings as fire resistant enclosures) do not maintain the fire resistant separation of the stair to comply with 19.3.1. and 7.1.3.2.2 Example conditions include:
* Numerous panels do not carry a minimum 1 1/2 hour fire resistant rating due to the lack of a U.L. listed label.

* Numerous panels are not self-closing to comply with 8.2.5.4(1) and 8.2.3.2.3.1(1). The access doors when released did not close to latch on their own.

* The stair wall opening at the access doors is not sealed to prevent the passage of smoke and fire to comply with 8.2.5.4(1) and 8.2.3.2.4.2. Surveyor observed unsealed concrete block cores.

B) Corrected 04/15/2010

C) Corrected 04/15/2010.

D) Corrected 04/15/2010.

E) Stair #8 First floor lacks separation from a utility pipe tunnel due to a pedestrian door which is not self closing to comply with 19.3.1.2 and 7.1.3.2.1 (d) except. # 2 for separation.

F) Stair #2 First floor does not comply with 19.3.1.2 and 7.1.3.2.1 (d) except. # 2 for separation due to a duct penetration which lacks a fire/smoke damper.

G) Stair #18 First floor does not comply with 19.3.1.2 and 7.1.3.2.1 (d) except. # 2 for separation due to an entry door which does not have latching hardware.

H). Corrected 04/15/2010.

I) Corrected 04/15/2010.

J). A series of deficiencies were observed relative to the Exit Stair # 5 located where the Hospital, the Physicians' Office Building, and the Chapel building meet. The Exit Stair serves Floors 1 through 8 of the Hospital, Floors 1 through 4 of the Physicians' Office Building, and Floors 1 and 2 of the Chapel Building. Surveyor 14290 notes that the Exit Discharge Enclosure for the Exit Stair is located within the Chapel Building. The following deficiencies were observed:
1. Storage Rooms were observed within the Exit Stair as prohibited by 7.1.3.2.1(d) and 7.2.2.5.3.. Storage Rooms were observed at the following landings:

a. Fourth Floor.
b. Third Floor.
2. Mechanical Rooms were observed that open into the Exit Stair as prohibited by 7.1.3.2.1(d). Mechanical Rooms were observed at the following landings:
a. Third Floor.

b. First Floor (within the Exit Discharge Enclosure).
3. Corrected 04/15/2010

4. Corrected 04/15/2010

A) Exit stairs are not configured and constructed to comply with 7.7.1 and/or 7.7.2: Six required exit stairs (# 2, # 5, # 6, # 7, # 8 and # 9) serve the 5th Floor and above. Of these six stairs - four of them discharge to the interior of the building (# 2, #5, # 8 and # 9) which does not comply with 7.7.2. Due to the lack of information concerning the location of smoke and fire barriers it could not be determined whether these stairs, which discharge to the interior of the building actually discharge into the same smoke compartment.
Example locations:

1. First floor Stair # 2 and Stair # 8 both discharge to the same corridor which is shown on the Life Safety drawings as a 2-hour rated corridor, however, it is not an exit passageway (refer to K-Tag 044).

2. First floor Stair # 5 discharges to the interior with an exit sign which leads to an elevator lobby.

A). Corrected 04/15/2010.


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B) UPDATE: 04/15/2010 It is the understanding that this item has become a project # 8791. (Revised 7/8/10 to 8971 by 13755) From random observation the surveyors find that means of egress are not readily available at all times:

1. Second floor East end corridor adjacent to Radiology suite is a dead end corridor exceeding 30 feet in length. This corridor terminates at one end into the Emergency Department Suite which does not comply with 19.2.5.9.

2. First floor South side corridor adjacent to CT/MRI suite is a dead end corridor exceeding 30 feet in length. This corridor terminates at one end into a room, the only second means of egress for this corridor is through a suite which does not comply with 19.2.5.9.


C). Corrected 04/15/2010.

A) Second floor Cath Lab suite shown as a designated suite on the Life Safety plans was observed to have an egress path which passes through at least 2 intervening rooms and is in excess of 50'-0" which does not comply with 19.2.5.8. The path noted is through the Recovery area and then through a restricted location to the corridor.

B) Third floor ICU suite "A"shown as a designated suite on the Life Safety plans was observed to have a pair of cross corridor doors which do not latch. Location observed: East exit out of the suite to a corridor adjacent to Surgery.

A) From random observation, the surveyors find that fire barriers (with two hour or greater fire ratings) are not installed and maintained in accordance with 8.2.3. This includes fire barriers that are used as horizontal exits and fire barriers that are used to separate buildings:

1. The 1st Floor 2-hour corridor for Stair # 2 and Stair # 8 has a designated two hour fire resistant rating as shown on the Life Safety Plan. Surveyor observed this 2-hour fire rated corridor is not separated from adjacent spaces and does not maintain a continuous safe means of egress due to the following:

a. multiple duct penetrations through the barrier walls above the suspended acoustical tile ceiling which do not have fire dampers.

b multiple pipe penetrations through the barrier walls above the suspended acoustical tile ceiilng which are not sealed against the passage of smoke and fire.

c. multiple access panels which are not self closing, lack a label indicating the fire resistance rating and do not have a fire rated sealant at the perimeter to maintain a compliant separation.


2. Corrected 04/15/2010.

3. Third floor 2-hour fire rated barrer between buildings located at West end patient care and MOB (not a designated horizontal exit) lacks a continuous fire rated separation due to the following:

a. Pair of cross corridor B-Labeled doors did not close and latch upon activation of the fire alarm.
.


B). The pair of doors at the designated 2 hour fire rated wall between the Second Floor of the Chapel and the Hospital to the south could not be verified as carrying a minimum 1-1/2 hour fire rating, required by 8.2.3.2.3.1(1), because no fire resistance rating label was visible.

A). The finding is that an exterior egress path was observed that is not provided with lighting, on emergency power, so that the failure of one fixture (bulb) will not leave the area in darkness, to comply with 19.2.8.

Example location observed: First floor Stair # 18 discharge


B). Numerous exit stairs contain light switches at each floor landing. It could not be verified that the minimum continuous illumination level is being provided to comply with 7.8.1.3.

A.) The surveyors find, from document review and facility walk through, that there is no definitive floor plan showing the necessary elements for evacuation and areas of refuge to comply with 19.7.2.2. Life Safety floor plans provided by the facility representatives lacked clearly defined smoke compartments. Facility personnel's knowledge related to location of smoke barriers, direction of travel for exit access (dead end corridor issues) and locations and sizes of suites (to comply with 19.2.5) appeared to conflict with the provided Life Safety floor plans.





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B). During a review of the facility's fire protection plan documents, compared to the survey walk through it was determined that the facility has not accurately maintained a comprehensive set of building floor plans, which show critical elements of its egress and fire/smoke compartmentalization systems, for compliance with 19.7.1.1. Critical elements of these systems which are not shown not shown accurately on the facility's Life Safety Master Plans include:

1. Locations and sizes of smoke compartments.

2. Designated suites including the perameter of the suite.

3. Sprinklered portions of the building and designated separations between sprinklered and non sprinklered areas.

4. Exit discharge enclosures designated exit passageways and their fire resistance.

5. The information shown on the facility's CADD generated Life Safety Plans is not clear due to indicating smoke barriers, fire resistant barriers(both 2 and 1 hour) and smoke tight walls all with similar line weight and color designations (i.e. red and orange).


C) (Modified 7/13/09): Based upon document review, the surveyor finds that the provider's written fire plan does not comply with 19.7.2 and that it is inconsistent with the acronym RACE:

RACE is a health care industry standard that stands for Rescue, Alarm, Compartmentation and Evacuate and/or Extinguish

1 The surveyor was shown two or more written fire plans that conflict with the steps identified under RACE and/or 19.7.2.

2 The "Alarm" portion of the RACE acronym is compromised. One component of the written fire plan, observed on site, indicates that staff are first to confirm the location of the fire and then close all doors in the area of activation and in adjacent areas. The steps are out of order and do not comply with the step by step requirements of 19.7.2.1. In another copy of the written plan, this step includes the zones above and below the location of the fire. The fire alarm system activates, throughout the entire facility with horns or chimes and strobes, as the same alarm condition (globally). The fire alarm system has no component that is designed to provide an announcement or other notification, automatically, throughout the facility to let personnel know the specific location of a fire.

3 The providers written procedures indicate that security is to notify the switchboard of the specific location of a fire and the switchboard is to make an overhead Code Red announcement that includes the location of the fire. In order to implement the provider's fire plan, personnel must wait for the overhead page to determine the procedures required as part of the fire plan.

4 The fire event on June 3, 2009, result in activation of the fire alarm system. Security mis-interpreted the alarm condition and notified the switchboard to announce a fire in the wrong location. The fire plan was not implemented in accordance with the requirements of NFPA 101 for this event.

D) The Department has a copy of the provider's written fire plan from an prior fire event. The document that is identified as Appendix P, St. Elizabeth's Hospital Fire Plan. Part B of this document includes a description of the RACE acronym with detailed steps. The steps identified in the written plan conflict with the standard requirements for RACE.

1 Under "Rescue", in the provider's written fire plan, immediate evacuation of a patient in immediate danger is not identified. Instead five steps are identified that involve patients that are not in immediate danger. These five steps belong in E for Evacuation.

2 The "Confine" or compartmentation component of their written plan does not indicate that all doors are to be closed to limit the spread of fire and smoke. Instead this component states that doors in the location of the fire and in the fire compartments above, below and adjacent are to be closed. The provider has no effective or accurate means to provide the location of a fire to all personnel. The delay that occurs when personnel wait to hear an overhead page is too long and the fire plan is therefore not implemented immediately.

3 Item 4 of their written fire plan identifies "E" as "Extinguish" as the last component of RACE. Evacuation is not identified in the fire plan as the last component of RACE. Instead evacuation is identified as the first step the staff should implement. The written plan does not identify the final step under "E" as "Evacuate or Extinguish" and does not include all of the steps that are included under their earlier step that is called "Rescue." This item in the written plan fails to identify the specific personnel that are authorized to order an evacuation of any type (see also 19.7.2.2).

A) Based upon a random review of fire drill documentation for the past 6 months, the surveyor finds that fire drills are not conducted in accordance with the Hospital's policies and/or not in accordance with 19.7.1.1, 19.7.1.2 and 19.7.2. of NFPA 101-2000.

1 Multiple areas or zones are documented for each fire drill that is conducted. However, most of the areas that are documented for each drill are not observed drills where staff performance is evaluated by a trained observer during the drill. Many of the forms identify fire drills where the area was evaluated by asking questions of staff, after an all clear was announced. Staff performance in such conditions are not being evaluated. Fire drills are always unannounced according to the provider and neither the observer nor the staff are able to identify the location of a fire, based upon activation and annunciation of the fire alarm system.

2 The fire drill reports do not indicate that staff performance includes whether they closed all doors (in the area observed). Instead the drill report forms ask the evaluator and staff, in the area observed, to determine where the fire is before they determine what procedures must be implemented. The fire alarm system is not designed to automatically notify all personnel of the location of a fire event.

3 The fire drill report form includes a line or question that is always marked "not applicable".

A.) First Floor ITT Department 1600: The corridor door leading to this suite did not latch to close upon activation of the fire alarm.


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B). Rooms or spaces were observed at which the fire alarm system audible alarm was not at least 10 dBA above the ambient noise level to comply with NFPA 72 1999 4-3.2.2. Locations observed:

1. Second floor Lab area near managers office. This part of the suite is used for patients and is not exclusive to staff.

C). Visual notification (strobe) devices were observed which did not activate during the test of the fire alarm system to comply with NFPA 72 1999 4-4.4.2.2. Location observed:

1. Second floor Lab near East Elevators




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D). During the tour of the first floor by the maintenance shop, eggcrate panels were observed in the ceiling grid compromising smoke detection by allowing byproducts of combustion to escape into the void above the detectors not in accordance with NFPA 72 1999 2-3.6.1.4 for flat ceiling surfaces.

E). During the fire alarm testing, smoke detector 4318 on the second floor was activated and the alarm notification devices did not function in accordance with NFPA 72 1999 1-5.4.2.2.

F). During the fire alarm testing, smoke detector 4318 on the second floor was activated and the double doors into the west business occupancy did not release in accordance with NFPA 72 1999 3-9.6.

A) Based upon document review, the surveyor finds that documentation of complete testing, maintenance and service of the fire alarm system is not maintained on site as a permanent record, in accordance with NFPA 72.

1. Documentation was not available on site for the annual sensitivity test of the smoke detectors to comply with NFPA 72 1999 7-3.2.1.




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UPDATE 04/15/2010
B). During the tour of the first floor by the maintenance shop, eggcrate panels were observed in the ceiling grid compromising smoke detection by allowing byproducts of combustion to escape into the void above the detectors not in accordance with NFPA 72 1999 2-3.6.1.4 for flat ceiling surfaces.

UPDATE 04/15/2010
C). During the fire alarm testing, smoke detector 4318 on the second floor was activated and the alarm notification devices did not function in accordance with NFPA 72 1999 1-5.4.2.2.

UPDATE 04/15/2010
D). During the fire alarm testing, smoke detector 4318 on the second floor was activated and the double doors into the west business occupancy did not release in accordance with NFPA 72 1999 3-9.6.

A). Based on document review and staff interview the surveyor finds that the facility does not conduct a from the floor inspection of the installed sprinkler system annually. NFPA 25, 1998, 2-2.1.1



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B). During interview with the "Director of Facilities" at the elevator equipment room it was confirmed the bottom of the hydraulic elevator shaft was not provided with sprinkler protection in accordance with 5-13.6.1.

C). During the document review process the weekly fire pump no flow test did not document the run time during the test. During staff interview in the "Director of Facilities" office the facility mechanic verified the test length was less than 10 minutes and not in accordance with NFPA 25 1998 5-3.2.1 for a minimum of 10 minutes.

A). Based on random observation during the survey walk through, the surveyor finds that sprinkler heads were coated with debris and were corroded which does not comply with NFPA 25 1998, 2-2.1.1. Locations observed include:

1. First floor Bed Storage



B). Based on random observation during the survey walk through, sprinkler heads have been painted which does not comply with NFPA 25, 1998, 2-2.1.1. Location observed:

1. First floor Bed Storage



C) Based upon observation and personnel interview, the surveyor finds that hospital personnel are not technically familiar with the building sprinkler system as a life safety system in the hospital, in accordance with 19.7.1.3:

1 During the fire event of June 3, 2009, hospital personnel were unable to locate and shut water off to the sprinkler zone of activation.

2 On June 4, 2009, the provider had to bring in an outside sprinkler contractor to first identify the correct location for the control valve, inspector's test location and flow switch for the sprinkler zone in question from June 3, 2009. The same contractor was necessary to demonstrate a functional test if this system.

3 Based upon a review of fire alarm documentation on June 3, 2009, the sprinkler system activated the fire alarm system in accordance with NFPA 13 and NFPA 72. However, the hospital failed to interpret, identify and announce the first alarm condition. Instead they interpreted a second alarm condition as the source of the fire and announced overhead an incorrect location of the fire.

D) Based upon interview, the surveyor finds that the sprinkler system is being tested by the outside contractor. However, no documeration was available on site that shows quarterly flow testing and annual testing, maintenance and servicing in accordance with NFPA 25.

A). During document review it was noted that the fire and smoke damper report indicated the facility failed to inspect and maintain dampers every 4 years to comply with 90A 3-4.7. Example items noted:

1. Page 2 of the smoke damper testing report revealed SD 401 - SD 508 had not been maintained since May-2005.

2. Page 2 of the smoke damper testing report revealed SD 601 - SD 813 had not been maintained since April-2005.

3. Pages 8, 9 and 10 indicates fire dampers in A and C buildings not maintained since April 05 and May 2005.

4. The fire damper report indicates 18 locations with no access to the fire dampers. The facility could not provide documentation of access panels installed and dampers maintained since May - 2005.

B). Corrected 04/15/2010.

C). On the Third floor 2 smoke dampers were observed to be installed more than 2 feet from the barrier wall which does not comply with 3-3.5.1.

Surveyor: 20224
D). During document review and staff interview it was determined that the dampers were last tested in May of 2005. However, not all of the dampers were indicated as having been tested at that time. During discussion with the facility representative the facility understood that the next testing and maintenance of the dampers would be in May of 2009. The surveyor reminded the facility that NFPA 90A 1999 requires testing every four years. Therefore, the facility has not yet tested all of the dampers to remain current.

A) From random observation, the surveyors find that trash and line chutes do not comply with NFPA 82:

1. The First floor Linen Chute Discharge Room

a) The room is not identified on plans as a two hour fire rated enclosure.

b) The ceiling in this room is heavily coated with lint and dust.

A). Corrected 04/15/2010.


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B). During the survey walk-through medical gas lines were observed supported by other means than in accordance with NFPA 99 1999 4-3.1.2.9(b) from the structure. Example locations:

1. First floor corridor on the west end of the corridor leading to stair #1.

2. First floor corridor above the ceiling by the maintenance shop.

3. First floor corridor doors leading to the dining room.

C). During the survey walk-through medical gas lines were observed without labeling in accordance with 4-3.1.2.14. Example locations:

1. Above the ceiling by the first floor corridor doors leading to the dining room.

2. Trash chute room 1518 was observed to have 3 medical gas lines.

3. Corrected 04/15/2010.

4. Corrected 04/15/2010.

5. Eighth floor east corridor 3 service valves

D). The 2 blood draw rooms in the laboratory were observed to have surface mounted medical vacuum and oxygen piped from above the ceiling with 3/8" tubing down to the outlets, not in accordance with 4-3.1.2.7 (c) for 1/2" down to within 8" of the outlets.

E). Corrected 04/15/2010.

A). Not all components of the Type 1 emergency generator are installed in accordance with NFPA 99 and 110 1999. During the survey walk-through, the emergency generator locations were observed to not be provided with battery powered lighting in accordance with NFPA 110 5-3.1. Locations include;

1. Emergency generator #1 120/208 enclosure.

2. Emergency generator #2 120/208 enclosure.

3. Emergency generator #1 277/480 enclosure.

4. Emergency generator #2 277/480 enclosure.

A). Interim Life Safety Measures: 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). During the document review process records of generator repairs were observed not listing parts replaced to comply with NFPA 110 3-4.4.2.

B). Testing records were not available for the generator after repair to comply with NFPA 110 6-3.4 (d).

C). Weekly generator inspections did not indicate water jacket temperature for compliance with NFPA 99 3-4.1.1.9 for maintaining jacket temperature above 90 degrees.

D). Monthly generator exercising under load shows the following generators did not meet the 30% of name plate rating each month to comply with 6-4.2.

1. generator #1 120/208
2. generator #1 277/480

A). Outlets were observed in critical patient care areas not identified with the panel and circuit serving the outlets to comply with NFPA 70 1999 517-19 (a). Example locations:

1. ICU patient rooms.

2. Emergency Department exam rooms.

3. PACU rooms.

4. CCU rooms.

5. Cardiac Cath rooms.

A). The elevator equipment room for the hydraulic elevator was not provided with smoke detection in accordance with ANSI 17.3.

A) There are numerous locations throughout the facility where doors in exit access corridors were observed that are not equipped with a positive latching hardware to comply with 19.3.6.2. Example locations observed:

1. Corrected 04/15/2010.

2. Corrected 04/15/2010.

3. Corrected 04/15/2010.

4. Corrected 04/15/2010.


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5. Corrected 04/15/2010.

6. Corrected 04/15/2010.

7. Corrected 04/15/2010.

8. UPDATE: 04/15/2010 The corrective item remains unchanged. Room # 2521 and # 2523 Near Radiology.


B) Corrected 04/15/2010.

A). Corrected 04/15/2010

B). Corrected 04/15/2010.




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C) From random observations, the surveyors find that vertical openings are not enclosed and protected in accordance with 19.3.1.1 and NFPA 90A. There are no shafts identified on the 2009 Life Safety Code Plans. In too many locations to list, the surveyors observed shaft enclosures that were not enclosed in fire rated enclosures. General deficiencies include but are not limited to:

* Shafts are open to the ceiling cavities of adjacent spaces.

* Shafts have multiple penetrations of voids that are not sealed

* Shafts have access panels that are not fire rated and not self closing

Example locations include but are not limited to:

1. First floor Pharmacy Storage (deemed a hazardous area): The shaft located on the west wall (approximatley the center of this wall) is incomplete above the finished ceiling.

2. Corrected 04/15/2010

3. Corrected 04/15/2010


D). Access panels in ventilation and pipe shafts were observed that do not maintain the fire resistant rating for the shaft enclosure due to the apparent improper installation of the access door frame which allows for a large opening and a continuous gap surrounding the frame which does not comply with 8.2.5. Other locations noted include access panels installed with continuous wood nailers. This condition appears through out the facility. Example location observed: Fifth floor medication room with dumbwaiter

E). Corrected 04/15/2010

Surveyor: 26665

F). Patient bathrooms were observed to have recessed medicine cabinets in the exhaust duct chase with no fire rating on the medicine cabinets in accordance with 3-3.4.1. Areas include;

1. Fourth Floor.

2. Fifth floor.

3. Sixth floor.

4. Seventh floor.

5. Eighth floor.

G). The equipment room on fifth floor was observed to have ductwork exiting and penetrating the fourth floor roof at 2 locations. The west duct penetrations were observed in the sleep study area which were not enclosed in a fire rated shaft to comply with 3-3.4.1.

H). At the time of the survey it could not be verified if the east duct penetrations into the sleep study area were enclosed to comply with 3-3.4.1 due to patient occupancy.

A). Due to the lack of clearly indicated smoke barriers on all floors of the Facility provided Life Safety Plans. It appears that the travel distance from one smoke compartment to the next exceeds the allowable maximum distance. Example location observed: First floor, central part of building including Mechanical, housekeeping, shipping recieving, bed storage, cafeteria and other adjacent areas (this does not include the possible 2-hour barrier adjacent to the kitchen).

A.) Fourth Floor- Patient Service Room 4266: The surveyor finds that this former Patient Room which has been converted into a Patient Service Room is being used as an office and for storing patient's medical records which due to the amount of storage is considered a hazardous area. The door is not self-closing to comply with 19.3.2.1.

B.) Corrected 04/15/2010.

C.) Corrected 04/15/2010.




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D) Corrected 04/15/2010

A) Numerous access panels in designated exit stairs throughout the facility (stair shafts are indicated on the facility life safety drawings as fire resistant enclosures) do not maintain the fire resistant separation of the stair to comply with 19.3.1. and 7.1.3.2.2 Example conditions include:
* Numerous panels do not carry a minimum 1 1/2 hour fire resistant rating due to the lack of a U.L. listed label.

* Numerous panels are not self-closing to comply with 8.2.5.4(1) and 8.2.3.2.3.1(1). The access doors when released did not close to latch on their own.

* The stair wall opening at the access doors is not sealed to prevent the passage of smoke and fire to comply with 8.2.5.4(1) and 8.2.3.2.4.2. Surveyor observed unsealed concrete block cores.

B) Corrected 04/15/2010

C) Corrected 04/15/2010.

D) Corrected 04/15/2010.

E) Stair #8 First floor lacks separation from a utility pipe tunnel due to a pedestrian door which is not self closing to comply with 19.3.1.2 and 7.1.3.2.1 (d) except. # 2 for separation.

F) Stair #2 First floor does not comply with 19.3.1.2 and 7.1.3.2.1 (d) except. # 2 for separation due to a duct penetration which lacks a fire/smoke damper.

G) Stair #18 First floor does not comply with 19.3.1.2 and 7.1.3.2.1 (d) except. # 2 for separation due to an entry door which does not have latching hardware.

H). Corrected 04/15/2010.

I) Corrected 04/15/2010.

J). A series of deficiencies were observed relative to the Exit Stair # 5 located where the Hospital, the Physicians' Office Building, and the Chapel building meet. The Exit Stair serves Floors 1 through 8 of the Hospital, Floors 1 through 4 of the Physicians' Office Building, and Floors 1 and 2 of the Chapel Building. Surveyor 14290 notes that the Exit Discharge Enclosure for the Exit Stair is located within the Chapel Building. The following deficiencies were observed:
1. Storage Rooms were observed within the Exit Stair as prohibited by 7.1.3.2.1(d) and 7.2.2.5.3.. Storage Rooms were observed at the following landings:

a. Fourth Floor.
b. Third Floor.
2. Mechanical Rooms were observed that open into the Exit Stair as prohibited by 7.1.3.2.1(d). Mechanical Rooms were observed at the following landings:
a. Third Floor.

b. First Floor (within the Exit Discharge Enclosure).
3. Corrected 04/15/2010

4. Corrected 04/15/2010

A) Exit stairs are not configured and constructed to comply with 7.7.1 and/or 7.7.2: Six required exit stairs (# 2, # 5, # 6, # 7, # 8 and # 9) serve the 5th Floor and above. Of these six stairs - four of them discharge to the interior of the building (# 2, #5, # 8 and # 9) which does not comply with 7.7.2. Due to the lack of information concerning the location of smoke and fire barriers it could not be determined whether these stairs, which discharge to the interior of the building actually discharge into the same smoke compartment.
Example locations:

1. First floor Stair # 2 and Stair # 8 both discharge to the same corridor which is shown on the Life Safety drawings as a 2-hour rated corridor, however, it is not an exit passageway (refer to K-Tag 044).

2. First floor Stair # 5 discharges to the interior with an exit sign which leads to an elevator lobby.

A). Corrected 04/15/2010.


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B) UPDATE: 04/15/2010 It is the understanding that this item has become a project # 8791. (Revised 7/8/10 to 8971 by 13755) From random observation the surveyors find that means of egress are not readily available at all times:

1. Second floor East end corridor adjacent to Radiology suite is a dead end corridor exceeding 30 feet in length. This corridor terminates at one end into the Emergency Department Suite which does not comply with 19.2.5.9.

2. First floor South side corridor adjacent to CT/MRI suite is a dead end corridor exceeding 30 feet in length. This corridor terminates at one end into a room, the only second means of egress for this corridor is through a suite which does not comply with 19.2.5.9.


C). Corrected 04/15/2010.

A) Second floor Cath Lab suite shown as a designated suite on the Life Safety plans was observed to have an egress path which passes through at least 2 intervening rooms and is in excess of 50'-0" which does not comply with 19.2.5.8. The path noted is through the Recovery area and then through a restricted location to the corridor.

B) Third floor ICU suite "A"shown as a designated suite on the Life Safety plans was observed to have a pair of cross corridor doors which do not latch. Location observed: East exit out of the suite to a corridor adjacent to Surgery.

A) From random observation, the surveyors find that fire barriers (with two hour or greater fire ratings) are not installed and maintained in accordance with 8.2.3. This includes fire barriers that are used as horizontal exits and fire barriers that are used to separate buildings:

1. The 1st Floor 2-hour corridor for Stair # 2 and Stair # 8 has a designated two hour fire resistant rating as shown on the Life Safety Plan. Surveyor observed this 2-hour fire rated corridor is not separated from adjacent spaces and does not maintain a continuous safe means of egress due to the following:

a. multiple duct penetrations through the barrier walls above the suspended acoustical tile ceiling which do not have fire dampers.

b multiple pipe penetrations through the barrier walls above the suspended acoustical tile ceiilng which are not sealed against the passage of smoke and fire.

c. multiple access panels which are not self closing, lack a label indicating the fire resistance rating and do not have a fire rated sealant at the perimeter to maintain a compliant separation.


2. Corrected 04/15/2010.

3. Third floor 2-hour fire rated barrer between buildings located at West end patient care and MOB (not a designated horizontal exit) lacks a continuous fire rated separation due to the following:

a. Pair of cross corridor B-Labeled doors did not close and latch upon activation of the fire alarm.
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B). The pair of doors at the designated 2 hour fire rated wall between the Second Floor of the Chapel and the Hospital to the south could not be verified as carrying a minimum 1-1/2 hour fire rating, required by 8.2.3.2.3.1(1), because no fire resistance rating label was visible.

A). The finding is that an exterior egress path was observed that is not provided with lighting, on emergency power, so that the failure of one fixture (bulb) will not leave the area in darkness, to comply with 19.2.8.

Example location observed: First floor Stair # 18 discharge


B). Numerous exit stairs contain light switches at each floor landing. It could not be verified that the minimum continuous illumination level is being provided to comply with 7.8.1.3.

A.) The surveyors find, from document review and facility walk through, that there is no definitive floor plan showing the necessary elements for evacuation and areas of refuge to comply with 19.7.2.2. Life Safety floor plans provided by the facility representatives lacked clearly defined smoke compartments. Facility personnel's knowledge related to location of smoke barriers, direction of travel for exit access (dead end corridor issues) and locations and sizes of suites (to comply with 19.2.5) appeared to conflict with the provided Life Safety floor plans.





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B). During a review of the facility's fire protection plan documents, compared to the survey walk through it was determined that the facility has not accurately maintained a comprehensive set of building floor plans, which show critical elements of its egress and fire/smoke compartmentalization systems, for compliance with 19.7.1.1. Critical elements of these systems which are not shown not shown accurately on the facility's Life Safety Master Plans include:

1. Locations and sizes of smoke compartments.

2. Designated suites including the perameter of the suite.

3. Sprinklered portions of the building and designated separations between sprinklered and non sprinklered areas.

4. Exit discharge enclosures designated exit passageways and their fire resistance.

5. The information shown on the facility's CADD generated Life Safety Plans is not clear due to indicating smoke barriers, fire resistant barriers(both 2 and 1 hour) and smoke tight walls all with similar line weight and color designations (i.e. red and orange).


C) (Modified 7/13/09): Based upon document review, the surveyor finds that the provider's written fire plan does not comply with 19.7.2 and that it is inconsistent with the acronym RACE:

RACE is a health care industry standard that stands for Rescue, Alarm, Compartmentation and Evacuate and/or Extinguish

1 The surveyor was shown two or more written fire plans that conflict with the steps identified under RACE and/or 19.7.2.

2 The "Alarm" portion of the RACE acronym is compromised. One component of the written fire plan, observed on site, indicates that staff are first to confirm the location of the fire and then close all doors in the area of activation and in adjacent areas. The steps are out of order and do not comply with the step by step requirements of 19.7.2.1. In another copy of the written plan, this step includes the zones above and below the location of the fire. The fire alarm system activates, throughout the entire facility with horns or chimes and strobes, as the same alarm condition (globally). The fire alarm system has no component that is designed to provide an announcement or other notification, automatically, throughout the facility to let personnel know the specific location of a fire.

3 The providers written procedures indicate that security is to notify the switchboard of the specific location of a fire and the switchboard is to make an overhead Code Red announcement that includes the location of the fire. In order to implement the provider's fire plan, personnel must wait for the overhead page to determine the procedures required as part of the fire plan.

4 The fire event on June 3, 2009, result in activation of the fire alarm system. Security mis-interpreted the alarm condition and notified the switchboard to announce a fire in the wrong location. The fire plan was not implemented in accordance with the requirements of NFPA 101 for this event.

D) The Department has a copy of the provider's written fire plan from an prior fire event. The document that is identified as Appendix P, St. Elizabeth's Hospital Fire Plan. Part B of this document includes a description of the RACE acronym with detailed steps. The steps identified in the written plan conflict with the standard requirements for RACE.

1 Under "Rescue", in the provider's written fire plan, immediate evacuation of a patient in immediate danger is not identified. Instead five steps are identified that involve patients that are not in immediate danger. These five steps belong in E for Evacuation.

2 The "Confine" or compartmentation component of their written plan does not indicate that all doors are to be closed to limit the spread of fire and smoke. Instead this component states that doors in the location of the fire and in the fire compartments above, below and adjacent are to be closed. The provider has no effective or accurate means to provide the location of a fire to all personnel. The delay that occurs when personnel wait to hear an overhead page is too long and the fire plan is therefore not implemented immediately.

3 Item 4 of their written fire plan identifies "E" as "Extinguish" as the last component of RACE. Evacuation is not identified in the fire plan as the last component of RACE. Instead evacuation is identified as the first step the staff should implement. The written plan does not identify the final step under "E" as "Evacuate or Extinguish" and does not include all of the steps that are included under their earlier step that is called "Rescue." This item in the written plan fails to identify the specific personnel that are authorized to order an evacuation of any type (see also 19.7.2.2).

A) Based upon a random review of fire drill documentation for the past 6 months, the surveyor finds that fire drills are not conducted in accordance with the Hospital's policies and/or not in accordance with 19.7.1.1, 19.7.1.2 and 19.7.2. of NFPA 101-2000.

1 Multiple areas or zones are documented for each fire drill that is conducted. However, most of the areas that are documented for each drill are not observed drills where staff performance is evaluated by a trained observer during the drill. Many of the forms identify fire drills where the area was evaluated by asking questions of staff, after an all clear was announced. Staff performance in such conditions are not being evaluated. Fire drills are always unannounced according to the provider and neither the observer nor the staff are able to identify the location of a fire, based upon activation and annunciation of the fire alarm system.

2 The fire drill reports do not indicate that staff performance includes whether they closed all doors (in the area observed). Instead the drill report forms ask the evaluator and staff, in the area observed, to determine where the fire is before they determine what procedures must be implemented. The fire alarm system is not designed to automatically notify all personnel of the location of a fire event.

3 The fire drill report form includes a line or question that is always marked "not applicable".

A.) First Floor ITT Department 1600: The corridor door leading to this suite did not latch to close upon activation of the fire alarm.


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B). Rooms or spaces were observed at which the fire alarm system audible alarm was not at least 10 dBA above the ambient noise level to comply with NFPA 72 1999 4-3.2.2. Locations observed:

1. Second floor Lab area near managers office. This part of the suite is used for patients and is not exclusive to staff.

C). Visual notification (strobe) devices were observed which did not activate during the test of the fire alarm system to comply with NFPA 72 1999 4-4.4.2.2. Location observed:

1. Second floor Lab near East Elevators




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D). During the tour of the first floor by the maintenance shop, eggcrate panels were observed in the ceiling grid compromising smoke detection by allowing byproducts of combustion to escape into the void above the detectors not in accordance with NFPA 72 1999 2-3.6.1.4 for flat ceiling surfaces.

E). During the fire alarm testing, smoke detector 4318 on the second floor was activated and the alarm notification devices did not function in accordance with NFPA 72 1999 1-5.4.2.2.

F). During the fire alarm testing, smoke detector 4318 on the second floor was activated and the double doors into the west business occupancy did not release in accordance with NFPA 72 1999 3-9.6.

A) Based upon document review, the surveyor finds that documentation of complete testing, maintenance and service of the fire alarm system is not maintained on site as a permanent record, in accordance with NFPA 72.

1. Documentation was not available on site for the annual sensitivity test of the smoke detectors to comply with NFPA 72 1999 7-3.2.1.




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UPDATE 04/15/2010
B). During the tour of the first floor by the maintenance shop, eggcrate panels were observed in the ceiling grid compromising smoke detection by allowing byproducts of combustion to escape into the void above the detectors not in accordance with NFPA 72 1999 2-3.6.1.4 for flat ceiling surfaces.

UPDATE 04/15/2010
C). During the fire alarm testing, smoke detector 4318 on the second floor was activated and the alarm notification devices did not function in accordance with NFPA 72 1999 1-5.4.2.2.

UPDATE 04/15/2010
D). During the fire alarm testing, smoke detector 4318 on the second floor was activated and the double doors into the west business occupancy did not release in accordance with NFPA 72 1999 3-9.6.

A). Based on document review and staff interview the surveyor finds that the facility does not conduct a from the floor inspection of the installed sprinkler system annually. NFPA 25, 1998, 2-2.1.1



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B). During interview with the "Director of Facilities" at the elevator equipment room it was confirmed the bottom of the hydraulic elevator shaft was not provided with sprinkler protection in accordance with 5-13.6.1.

C). During the document review process the weekly fire pump no flow test did not document the run time during the test. During staff interview in the "Director of Facilities" office the facility mechanic verified the test length was less than 10 minutes and not in accordance with NFPA 25 1998 5-3.2.1 for a minimum of 10 minutes.

A). Based on random observation during the survey walk through, the surveyor finds that sprinkler heads were coated with debris and were corroded which does not comply with NFPA 25 1998, 2-2.1.1. Locations observed include:

1. First floor Bed Storage



B). Based on random observation during the survey walk through, sprinkler heads have been painted which does not comply with NFPA 25, 1998, 2-2.1.1. Location observed:

1. First floor Bed Storage



C) Based upon observation and personnel interview, the surveyor finds that hospital personnel are not technically familiar with the building sprinkler system as a life safety system in the hospital, in accordance with 19.7.1.3:

1 During the fire event of June 3, 2009, hospital personnel were unable to locate and shut water off to the sprinkler zone of activation.

2 On June 4, 2009, the provider had to bring in an outside sprinkler contractor to first identify the correct location for the control valve, inspector's test location and flow switch for the sprinkler zone in question from June 3, 2009. The same contractor was necessary to demonstrate a functional test if this system.

3 Based upon a review of fire alarm documentation on June 3, 2009, the sprinkler system activated the fire alarm system in accordance with NFPA 13 and NFPA 72. However, the hospital failed to interpret, identify and announce the first alarm condition. Instead they interpreted a second alarm condition as the source of the fire and announced overhead an incorrect location of the fire.

D) Based upon interview, the surveyor finds that the sprinkler system is being tested by the outside contractor. However, no documeration was available on site that shows quarterly flow testing and annual testing, maintenance and servicing in accordance with NFPA 25.

A). During document review it was noted that the fire and smoke damper report indicated the facility failed to inspect and maintain dampers every 4 years to comply with 90A 3-4.7. Example items noted:

1. Page 2 of the smoke damper testing report revealed SD 401 - SD 508 had not been maintained since May-2005.

2. Page 2 of the smoke damper testing report revealed SD 601 - SD 813 had not been maintained since April-2005.

3. Pages 8, 9 and 10 indicates fire dampers in A and C buildings not maintained since April 05 and May 2005.

4. The fire damper report indicates 18 locations with no access to the fire dampers. The facility could not provide documentation of access panels installed and dampers maintained since May - 2005.

B). Corrected 04/15/2010.

C). On the Third floor 2 smoke dampers were observed to be installed more than 2 feet from the barrier wall which does not comply with 3-3.5.1.

Surveyor: 20224
D). During document review and staff interview it was determined that the dampers were last tested in May of 2005. However, not all of the dampers were indicated as having been tested at that time. During discussion with the facility representative the facility understood that the next testing and maintenance of the dampers would be in May of 2009. The surveyor reminded the facility that NFPA 90A 1999 requires testing every four years. Therefore, the facility has not yet tested all of the dampers to remain current.

A) From random observation, the surveyors find that trash and line chutes do not comply with NFPA 82:

1. The First floor Linen Chute Discharge Room

a) The room is not identified on plans as a two hour fire rated enclosure.

b) The ceiling in this room is heavily coated with lint and dust.

A). Corrected 04/15/2010.


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B). During the survey walk-through medical gas lines were observed supported by other means than in accordance with NFPA 99 1999 4-3.1.2.9(b) from the structure. Example locations:

1. First floor corridor on the west end of the corridor leading to stair #1.

2. First floor corridor above the ceiling by the maintenance shop.

3. First floor corridor doors leading to the dining room.

C). During the survey walk-through medical gas lines were observed without labeling in accordance with 4-3.1.2.14. Example locations:

1. Above the ceiling by the first floor corridor doors leading to the dining room.

2. Trash chute room 1518 was observed to have 3 medical gas lines.

3. Corrected 04/15/2010.

4. Corrected 04/15/2010.

5. Eighth floor east corridor 3 service valves

D). The 2 blood draw rooms in the laboratory were observed to have surface mounted medical vacuum and oxygen piped from above the ceiling with 3/8" tubing down to the outlets, not in accordance with 4-3.1.2.7 (c) for 1/2" down to within 8" of the outlets.

E). Corrected 04/15/2010.

A). Not all components of the Type 1 emergency generator are installed in accordance with NFPA 99 and 110 1999. During the survey walk-through, the emergency generator locations were observed to not be provided with battery powered lighting in accordance with NFPA 110 5-3.1. Locations include;

1. Emergency generator #1 120/208 enclosure.

2. Emergency generator #2 120/208 enclosure.

3. Emergency generator #1 277/480 enclosure.

4. Emergency generator #2 277/480 enclosure.

A). Interim Life Safety Measures: 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). During the document review process records of generator repairs were observed not listing parts replaced to comply with NFPA 110 3-4.4.2.

B). Testing records were not available for the generator after repair to comply with NFPA 110 6-3.4 (d).

C). Weekly generator inspections did not indicate water jacket temperature for compliance with NFPA 99 3-4.1.1.9 for maintaining jacket temperature above 90 degrees.

D). Monthly generator exercising under load shows the following generators did not meet the 30% of name plate rating each month to comply with 6-4.2.

1. generator #1 120/208
2. generator #1 277/480

A). Outlets were observed in critical patient care areas not identified with the panel and circuit serving the outlets to comply with NFPA 70 1999 517-19 (a). Example locations:

1. ICU patient rooms.

2. Emergency Department exam rooms.

3. PACU rooms.

4. CCU rooms.

5. Cardiac Cath rooms.

A). The elevator equipment room for the hydraulic elevator was not provided with smoke detection in accordance with ANSI 17.3.