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A) From random observation the surveyor finds that combustible materials have been used that are incompatible with the buildings construction type and that are not permitted in Type I or Type II construction (19.1.6.2). Failure to maintain fire rated assemblies could cause early failure during a fire emergency.

Findings include:

1) The construction type for the North Clinic is Type I (332) or Type II (222). The construction type for the Center Wing of the Hospital is Type I (332) or Type II (222). The Northeast Mechanical Room that is located north of the west wing of the North Clinic is separated from both buildings by a two hour fire barrier. The roof of this mechanical room has a void in it with a plywood roof patch or plywood housing above. The plywood is not compatible with the construction type of the buildings.

B) Corrected 04/18/13

End

A) From random observation, the surveyor finds that combustible materials have been used that are incompatible with the building's construction type and that are not permitted in Type I or Type II construction (19.1.6.2, 19.1.6.3). These deficiencies could contribute fuel load in a fire and cause earlier failure of the building structure.

Findings include:

1) The Basement Level of the Rogers and Concourse Wings have a Mechanical Room on the west side of the building that communicates to a vertical air intake shaft. The construction of this shaft has multiple deficiencies which include lack of compliance with 19.1.6.2:

a) Looking up the shaft from the bottom, there is a steel grate at the top of the shaft that supports a floor or roof assembly. No information was available and the floor of roof does not comply with the requirements of Type II (222) construction.

b) The air intake shaft communicates to a "doghouse" structure that sits on the roof of the 2nd Floor and includes the north wall of the 3rd Floor On-Call Rooms in the Center Wing. The doghouse has plywood on the north side of the north wall of the On-Call Rooms. The doghouse has an unprotected steel joist roof structure (unprotected steel) that is covered with plywood. The plywood and unprotected steel joists are not compatible with Type II (222) construction and/or Type I (332).


16339


A. Corrected 04/19/13

B. Corrected 04/19/13

C. Corrected 04/19/13







20224

Based on random observation and staff interview during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. This deficiency could affect any patients, staff, or visitors in that portion of the building because the building structure in that area could fail under fire conditions more quickly than in other parts of the building.

Findings include:

A. Afternoon of 07/17/12, 3 bank elevator shaft, Parkview all floors; the third elevator shaft has been filled in to produce a room on every floor. These rooms have exposed structural steel decking. The facility representatives did not have a U.L. listed rating for the floor assembly in order to comply with the building's construction type.

04/19/13: The documentation for the above item does not include the support angles on two of four sides of the floor system. Alternatively the documentation does not clearly indicate that the steel angles are none load bearing and that they can be removed.

1) Corrected 04/19/13

2) Corrected 04/19/13

3) (New 04/19/13): The 1st Floor Concourse area is an enclosed "breezeway" with seating, vending and an open cafe (multiple uses). This space also serves as a required means of egress. The space does not comply with the exceptions under 19.3.6.1. Although cameras are used, to observe this space; however, cameras are not generally accepted as the substitution of direct observation/supervision 24/7. The space lacks smoke detection throughout in accordance with 19.3.6.1 exception # 1.



16339


A. Corrected 04/19/13

B. Corrected 04/19/13

C. Corrected 04/19/13



20224

Based on random observation and staff interview during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all persons in the smoke compartment, compromising the separation of patient care areas from the location of fire origin.

Findings include:

A. Corrected 04/19/13

B. Morning of 07/18/12, 2nd floor, Concourse, Corridor located south of Recovery Stage I, was observed to be a noncompliant corridor due to a designated exit sign directing egress into an intervening room (the Recovery suite located in Parkview). This condition does not comply with 19.2.5.9 for any exit access corridor leading to two approved exits.
Based on observation on 04/19/13, the issue appears to be the lack of positive latching corridor doors. Provide an 8 1/2 x 11 floor plan with the PoC for this item.

C. Corrected 04/19/13

A) Based on random observation, the surveyor finds that corridor doors are not always positive latching in accordance with NFPA 101.

Findings include:

1) Basement Level of Mills Breast Cancer Center - near MRI: During fire alarm testing on the afternoon of 7/19/12, the surveyor observed an auto opening corridor door that did not close to latch upon activation of the fire alarm system. The auto-open/auto-hold-open functions continued to operate with the fire alarm activated. The surveyors find that the door is not positive latching in accordance with 18.3.6.3.2 with this condition.

Failure to close and latch doors to corridors could allow a fire or smoke to spread into the corridor.

End

A) Based on random observation, the surveyor finds that corridor doors are not always positive latching in accordance with 19.3.6.3.2 and/or that corridor doors are not installed to maintain a smoke tight condition.

Findings include:

1) Center Wing Basement Level (near North Clinic): CT Scan Room # 1 has a pair of corridor doors that lack positive latching hardware.

2) Basement Storage Room (says CT MRI with an arrow): This room has a pair of corridor doors; one door does not latch.

3) Basement R/F Room 23 has a corridor door that is not positive latching.

4) Basement Level Nutrition Bulb Room - this room provides access to an electrical room with Transfer Switch A-3EOR. The pair of corridor doors do not latch and they have a gap between the doors that exceeds 1/8 (and are not designed to resist the passage of smoke).

5) Basement Level Parkview Staff Library: The corridor door has an electronic strike receiver that was not engaged. The provider indicates that the strike receiver latches at night, but was not able to identify when and how the corridor door is positive latching in accordance with 19.3.6.3.2 in the daytime.

6) 1st Floor Center Wing E D Suite: The pair of suite doors near the northeast Nurses' Station (near Exam Rm 19) have too much gap between the doors.

7) The 1st Floor Gift Shop (Center Wing) in the Main Lobby is roughly 900 square feet in area, but has not been evaluated as a hazardous area. The Lobby is part of the means of egress for an exit access corridor. The Gift Shop door lacks positive latching hardware in accordance with 19.3.6.3.2.

8) The Center Wing 1st Floor Chapel, located off of the Main Lobby, lacks a positive latching door in accordance with 19.3.6.3.2.

9) 2nd Floor Parkview/Rogers/Center Wing: This item is cited for all doors to rooms and/or doors at designated suite boundaries. All doors or pairs of doors with automatic opening functions and/or hold open functions failed to release the doors and latch upon activation of the fire alarm system in this area. The surveyors finds that there is a pattern that includes all of the doors to the Cath Labs Rooms, all Cath Lab Suite doors and the doors between prep/recovery and an old Cath Lab.

a) The above citation includes a pair of doors to Cath Lab # 8. The doors have panic devices and automatic opening functions that are enabled by sensors. The provider was unable to demonstrate when and how the doors can be closed and maintained in a latched position.

b) The above citation also includes a pair of cross-corridor suite doors where the strike receivers in the door frames had been removed.

c) The above citation includes a pair of opposite-swinging suite doors, (2 Center into 2 Rogers) one of two doors did not latch.

d) The above citation includes a pair of suite doors north of IR Lab # 6 which also has too much gap between the doors.

e) There is a pair of opposite-swinging, auto-open suite doors installed in a designated smoke barrier. Smoke detection with five feet of the doors is not installed in accordance with 7.2.1.8 and the doors have no functioning latching hardware for doors at a suite boundary.

Failure to maintain corridor doors in accordance with NFPA 101 could allow smoke to spread from room to room in a fire emergency

End


20224


Based on random observation and staff interview during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6..3.2 for a means to keep the door closed. This condition could affect patients, visitors and staff within an exit access corridor during a fire condition.

Findings include:

A. Afternoon of 07/18/12, 2nd floor, Concourse, Recovery Stage I, contains a corridor door that is aluminum framed glass. This door is not provided with a means suitable for keeping the door closed due to the lack of latching hardware.

B. Afternoon of 07/18/12, 2nd floor, Concourse, Recovery Stage I, contains a pair of corridor doors with an inactive leaf with a manual flush bolt which was not engaged. Due to this condition, the pair of doors are not provided with a means suitable for keeping them closed and latched.

C. Corrected 04/19/13

D. Afternoon of 07/17/12 8th floor Parkview CVCU (not a designated suite) contains patient rooms which are not separated from the exit access corridor due to sliding glass doors which do not latch when in the closed position.

A) Based on random observation, the surveyor finds that corridor doors are not always positive latching in accordance with NFPA 101.

Findings include:

1) Basement Level of the North Clinic - The Interventional Clinic (Suite S10 on the Life Safety Plans) - During fire alarm testing on the morning of 7/20/12, with the Safety Officer observing, the surveyor observed an auto opening corridor door that did not close to latch upon activation of the fire alarm system. The auto open/auto hold open functions continued to operate with the fire alarm activated and the door is not positive latching in accordance with 19.3.6.3.2 with this condition.

Failure to close and latch doors to corridors could allow a fire or smoke to spread into the corridor.

End

A) From random observation the surveyors find that vertical openings and/or penetrations through fire rated floor assemblies are not installed and maintained in accordance 8.2.5 of NFPA 101.

Findings include:

1) Corrected 04/19/13

2) Corrected 04/19/13

3) 2nd Floor Center Wing - there is a rated shaft enclosure in the southeast corner of the Cardiology Waiting Area. The shaft wall is incomplete near the duct penetrations though the floor below.

4) 2nd Floor Center Wing - there is a shaft enclosure in the Southwest corner of the Cardiology Waiting Area. This shaft has three ducts that penetrate multiple floors from the Basement to the roof of a 4th Floor Mechanical Space.

a) Fire rated shaft enclosures for multiple
floors are not identified on the Life
Safety Plans for the 1st, 2nd, 3rd, and
possibly the 4th Floor, in accordance with
NFPA 101 and NFPA 90A.

b) Fire rated shaft enclosures for multiple
floors are not provided for the 1st, 2nd,
3rd, and possible the 4th Floor, in
accordance with NFPA 101 and NFPA
90A. In some cases that shaft does not
exist. On the 2nd and 3rd Floors, the
shafts are drywalled on one side only.

c) The three ducts have fire dampers in the
floor at some floors where fire dampers
would not be permitted under NFPA
90A. See also Item 5 below.

5) 3rd Floor Center Building - Surgical Waiting Room: There is a duct shaft in the southeast corner of this room. The shaft does not comply:

a) The shaft enclosure is only drywalled on
one side; this shaft is not enclosed in fire
rated construction in accordance wish
19.3.1.1 and in accordance with NFPA
90A.

b) Three seamless 12" x 12" ducts
penetrate
the floor below and above without fire
dampers. The provider did not know
what these ducts connect to and had no
information that would indicate that the
ducts could comply with the rules for
hazardous ducts instead of the rules for
fire dampers under NFPA 90A.

6) Renumbered on 4/17/13: 3rd Floor Center Wing - Southeast Mechanical Room: The surveyor notes that that this space appears on plans to be part of the North Clinic at the 2nd and 3rd Floors. It is part of the Center Wing and is separated from the North Clinic by designated two hour fire barriers. This is not a deficiency.

7) Renumbered on 4/17/13: 4th Floor Center Wing West Mechanical Room - three seamless 12" x 12" ducts penetrate the floor below and the roof above without a fire rated shaft enclosure in this space in accordance with NFPA 90A.

Failure to protect openings in fire rated floors and failure to maintain vertical openings could allow fire to spread from floor to floor in a fire emergency.

End




16339

Based on random observation during the survey walk-through, not all ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.These deficiencies could affect any patients, as well as any staff and visitors because the failure to provide dampers and proper installation of shaft could result in smoke or fire passing from one part of the building to another.

Finding includes:

A. Corrected 04/19/13

B. North Tower Wing, 4th Floor, Med/Surge Unit - A ventilation shaft behind the Nurse Station near the Clean Room was observed with pipe and conduit penetrations through the two hour fire rated shaft wall, the penetrations are not rated in accordance with 8.2.3.2.4.2.

C. Concourse Wing, 1st Floor - Designated ventilation shaft near the Waiting Area was observed with ductwork penetrations that lack fire dampers and fire damper panels installed in accordance with NFPA 90A.

4/17/13: The surveyor observes that there is a very large "dead" space with no access; not enough information is provided to demonstrate that this is not a vertical opening.

D. Corrected 04/19/13

E. Corrected 04/19/13

F. North Tower Wing , Lower Level 1 Stair OAS3 - The door label to this required exit stair is missing.








20224

Based on random observation and staff interview during the survey walk-through on 6/13/12, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

Findings include:

A. Corrected 04/19/13

B. Corrected 04/19/13

C. Corrected 04/19/13

D. Morning of 07/17/12, 5th floor Rogers, Shaft # 506 (as shown on the Life Safety floor plans) does not maintain the 2-hour fire resistance rating to comply with 8.2.5 due to the following:

1. Large gaps surrounding duct
penetrations.

2. Large holes surrounding pipe
penetrations.

3. The framed opening for the access panel
does not provide a continuous closure for
the shaft wall construction to seal against
fire/smoke penetration.

Based on random observation during the survey walk-through, not all ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.These deficiencies could affect any patients, as well as any staff and visitors becaues the failure to provide dampers and proper installation of shaft could result in smoke or fire passing from one part of the building to another.

Finding includes:

A. Corrected 04/18/13

B. North Clinic Building, 4th Floor, a shaft located in the North East Clinic was observed with ductworks that lack a two hour fire rated separation wall and the shaft is exposed from the remainder of the building.

C. Corrected 04/18/13

D. North Clinic, First Floor - The surveyor finds that duct penetrations at shaft walls lack fire dampers in accordance with NFPA 90A. Locations include: Shaft located at the back wall of the Staff Only Room 1D023 near the Storage 1D019 as shown on the Life Safety drawings.

A) Based on fire alarm testing conducted on the afternoon of 7/19/12, and the morning of 07/20/12, with the Safety Officer and the Director of Facility Services, the surveyors find that required fire doors with hold open devices and/or auto open/auto hold open devices do not release from activation of the fire alarm system in accordance with 7.2.1.8. The surveyors observed this condition throughout most floors of most buildings.

Examples include but are not limited to

1) Basement Level North Clinic - the designed smoke barrier between the Center Wing of the Hospital and the North Clinic has a pair of smoke doors that failed to close upon activation of the fire alarm system in accordance with 7.2.1.8.

Failure to close fire doors during a fire will allow fire and smoke to spread to multiple buildings during a fire and will compromise required means of egress in a fire emergency.

End

A) Based on random observation throughout multiple buildings and based on fire alarm testing that was conducted (by Hospital engineering and management staff) on the afternoon of July 19, 2012 and the morning of July 20, 2012, the surveyors find that multiple fire doors and smoke doors failed to close (and latch where applicable) upon activation of the fire alarm system and sprinkler system. This condition is cited also in the North Clinic and the Tunnel to the Mills Breast Cancer Center. These conditions indicate a pattern of fire doors that do not comply with 19.2.2.2.6, 7.2.1.8.2. This citation includes fire and smoke doors with automatic opening functions.

Examples include but are not limited to:

1) 10th floor, North Tower, cross corridor doors, on magnetic hold open devices, leading from two north/south corridors into the C-Section semi restricted corridor failed to close upon activation of the fire alarm.

2) 7th Floor: The pair of designated smoke doors between Parkview/Rodgers and the Concourse Wing failed to release and close upon activation of the fire alarm system in this area.

3) Corrected 04/19/13

4) 2nd Floor Parkview/Rogers/Center Wing: This location is cited for all doors that are part of a designated smoke barrier. The surveyor finds that all doors or pairs of doors with automatic opening functions and all doors that have hold open functions failed to release the doors upon activation of the fire alarm system in this area. The surveyor notes that many of these doors are also part of a suite boundary and that the doors also failed to latch (this is cited also under K18). These conditions identify a pattern that includes all of the doors to the Cath Labs, all Cath Lab Suite doors, and the doors between prep/recovery and an old Cath Lab. The lack of room numbers makes specific identification difficult.

5) 2nd floor, North Tower, designated 2-hour barrier cross corridor doors on magnetic hold opens (located west of Sugery suite) did not close to a latched position (one of the doors was unable to close).

6) Corrected 04/19/13

7) Corrected 04/19/13

8) Lower Level, North Tower, designated 2-hour barrier cross corridor doors on magnetic hold opens (located north of Break Down room) did not close to a latched position.


B) Corrected 04/19/13

C) Corrected 04/19/13


End

A) Based on fire alarm testing conducted on the afternoon of 7/19/12, required fire doors with hold- open devices do not release from activation of the fire alarm system in accordance with 7.2.1.8.

Findings include:

1) The surveyors find that the pair of fire doors between the Tunnel and the South Clinic are part of a two hour fire separation between buildings. These doors have auto-open functions or hold-open functions that were not disabled from activation of the fire alarm system.

04/18/13: The above doors closed from fire alarm activation but failed to latch.

2) The surveyors find that the pair of fire doors between the Tunnel and the North Clinic are part of a two hour fire separation between buildings. These doors have auto-open functions or hold-open functions that were not disabled from activation of the fire alarm system on both sides of the fire doors.

04/18/13: The above doors closed from fire alarm activation from the the North Clinic but not from the fire alarm system in the Tunnel.

Failure to close fire doors during a fire will allow fire and smoke to spread to multiple buildings during a fire and will compromise required means of egress in a fire emergency.

End

A) Based random inspection, designated smoke barriers are not installed and maintained to comply with 19.3.7.3.

Findings include:

1) Basement Level Nuclear Medicare Room OEO22 (Note - it is not clear whether this space is located in the Center Wing of the Hospital or the North Clinic): This room was probably constructed as part of the North Clinic; however, there are no building separations on this level between the Hospital and the North Clinic. There is penetration above the ceiling, above the door to the room, that is sealed with drywall tape (not sealed with fire rated penetration construction materials in accordance with 8.2.4.4).

2) Corrected 04/19/13

3) The designated 2nd Floor smoke barrier north of Cath Lab # 4 has multiple penetrations which are sealed with drywall mud and tape (not fire rated penetration detail) and one sprinkler penetration that is not sealed.

Failure to maintain smoke barriers will allow smoke to spread from smoke compartment to smoke compartment in a fire emergency.

End


16339

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3.

Findings include:

A. Conduit and duct penetrations were observed in smoke barrier walls that are not sealed against the passage of smoke as required by 8.3.6.1. Locations observed include:

1. North Tower Wing, Tenth Floor, Telecom Closet.

The deficiencies noted above could affect any patients, as well as any staff and visitors because the failure to maintain smoke barriers will allow to spread from smoke compartment to smoke compartment in a fire emergency.



20224

Based on random observation and staff interview during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. This deficiency could affect any patients, staff, or visitors in the smoke compartments on either side of the cited wall by permitting smoke to pass between them.

Findings include:

A. Afternoon of 07/18/12, 4th floor, Concourse, the smoke barrier wall between Concourse and Parkview/Rogers does not comply with 19.3.7.3 and 8.3.2. The wall is not continuous from outside wall to outside wall due to the following:

1. Corrected 04/19/13

2. Upon inspection above the ceiling, the designated smoke barrier is incomplete due to the following:

i. Large gaps surrounding ductwork

ii. Large holes surrounding pipe
penetrations.

A) Based on random the surveyor finds that hazardous areas are not protected in accordance with 19.3.2.1 and 8.4.1 of NFPA 101:

Findings include:

1) The 1st Floor Center Wing Walgreen's retail Pharmacy is located in the Main Lobby of the Hospital. It has been evaluated as an existing hazardous area [and as a mixed (Mercantile) occupancy that is not separated from the Hospital]. The doors from the Main Lobby to the Pharmacy do not comply with 19.3.2.1.

a) There is a swinging door to the space
that is self closing but is not positive
latching.

b) There is a pair of automatic sliding doors
that no longer open and close
automatically. These doors are not self
closing in accordance with 19.3.2.1 and
7.2.1.8 and the doors lack positive
latching hardware.

2) 2nd Floor Center Building - Former procedures rooms have been converted to storage rooms and do not have one hour fire rated enclosures and 3/4 hour fire rated door assemblies:

a) EP Lab # 1

b) North IVS Storage Room

3) 2nd Floor Center Building - The Clean Supply Room opposite Vascular Lab # 2 had a self closing door; however closing device has been removed.

Failure to maintain separations for hazardous areas will increase the fuel load in a fire emergency and allow fire and smoke to spread outside to the spaces with higher fuel loads.

End


16339

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. These deficiencies could affect all patients, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous areas into the building's exit access corridors.

Findings include

A. In the morning of 07/19/2012, North Tower Wing and Concourse Wing Lower Level- The corridor doors (double doors) to CPD Storage Room do not positively latch to close to comply with 19.3.6.2 and 19.3.2.1.



20224

Based on random observation and staff interview during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access during a fire condition. Findings include:

A. Morning of 07/17/2012, 9th floor Parkview, contains mechanical rooms none of which are separated from occupied areas including:

1. The exit access corridors

2. Respiratory Care Staff area

3. Lodging Occupancy used on a 24/7 basis by EMT's and Life Flight personnel.

The Life Safety drawings indicate a fire resistance rating of 1-hour surrounding the Lodging occupancy from the mechanical rooms. The perimeter wall of the Lodging Suite does not exist above the suspended acoustical tile ceiling for the Lodging occupancy.

B. Morning of 07/18/12, 9th floor Parkview Respiratory Care Clean Storage was observed not separated from the occupied spaces including the corridor leading to offices, staff break and work rooms due to the lack of rated walls and doors.

C. Morning of 07/17/12, 8th floor Rogers, the Storage Room located between patient room #8867 and # 8865 contains a pair of entry doors which do not latch.

D,. Afternoon of 07/17/12, 7th floor, Linen Closet located across from room # 7675 contains a pair of doors with a manual throw which does not allow the doors to close and latch.

E. Afternoon of 07/17/21, 7th floor, Work room adjacent to the Nurse station contains numerous shelving units with plastic covered containers and is deemed to be storage. The entry door contains a closer with a disabled arm, thus the door is not self closing.

F. Morning of 07/18/12, 5th floor, Parkview, switchgear room's perimeter fire rated wall construction is compromised by the penetration of a pneumatic tube installation which passes through the wall and ceiling. This tube remains open through the wall to the adjacent mechanical room.

A) Based on observation, the surveyor finds that required exit stairs are not installed and maintained to provide a continuous safe path of travel in accordance with Chapter 7 and Chapter 8 or NFPA 101.

Findings include:

1) North Clinic Basement Level Center Stair does not comply with 7.1.3.2:

a) The stair has a door inside the stair
identifying a Mechanical Room OE 59.
This door is not a B Label Fire door and
is not self closing in accordance with
7.1.3.2.1 and NFPA 80.

b) One or more penetrations above the
ceiling in the stair are not sealed for fire
rated construction (8.2.3.2.4).

c) One duct penetration above the ceiling
(above the door from the lobby into the
stair) lacks a fire damper in accordance
with 7.2.1.3. e), exception # 1 and
NFPA 90A.

2) North Clinic Basement Level West Stair does not comply with 7.1.3.2

a) There is a space under the stair that is
full of junk. This space under the stair is
not isolated with fire rated construction
in accordance with 7.2.2.5.3. The door
to this space under the stair is not a fire
rated, self closing opening protected
assembly. The space is not sprinklered
in accordance with NFPA 13

3) North Clinic Basement Level East Stair does not comply with 7.1.3.2. There is a duct penetration of the stair wall above the ceiling that does not have a fire damper.

Failure to maintain exit enclosures could compromise the use of these exits in a fire emergency.

End



16339

Based on random observation, the surveyor finds that required exit stair enclosures do not provide a continuous path of escape and not provided protection against fire or smoke from other parts of the building to comply with Chapter 7. These deficiencies could affect any patients from this building and as well as any staff and visitors because designated exit stairs are not protected against fire or smoke conditions to comply with 8.2.5.2.

Findings include:

1. North Clinic, 7th Floor - Identified Stair NCW/NCE 7th Level was observed with electical junction box that does not directly serves the stair, according to staff the electrical system connects to the signage outside for the North Clinic Building.

2. Corrected 04/18/13

3. Corrected 04/18/13

A) The surveyor finds that exit enclosures are not installed and maintained in accordance with 7.1.3.2.1 of NFPA 101.

1) Corrected 04/19/13

2) 1st Floor Rogers West Stair - The require exit stair discharges into a small foyer that complies with the exception under 7.7.2 (2). However:

a) Corrected 04/19/13

b) The exit discharge door to the outside
and the door to the vestibule both have
magnetic locking devices. The provider
was not able to demonstrate how both
doors comply with 19.2.2.2.4. One door
had a sensor that did not always unlock
the door. One or both doors do not
comply with 7.2.1.6.2 (any blue pull
station devices that are installed to
release the doors do not comply with
7.2.1.6.2). It is not apparent whether one
or both doors are intended to comply
with 7.2.1.6.1; however only one door is
permitted to comply with 7.2.1.6.1,
based on 19.2.2.2.4.

3) 2nd Floor Northwest Stair of Center Wing - the stair has an unrated access panel to a concealed space that is not constructed as a fire barrier. Access behind is limited; however the space appears to have one or more duct penetrations. The ducts and the concealed space do not comply with 7.1.3.2.1 of NFPA 101.

Failure to maintain fire rated enclosures for exit stairs could compromise them in a fire emergency.

End



16339

Based on random observation, the surveyor find that requires exit stair enclosures do not provide a continuous path of escape and not provided protection against fire or smoke from other parts of the building to comply with Chapter 7. These deficiencies could affect any patients from this building and
as well as any staff and visitors because designated exit stairs are not protected against fire or smoke conditions to comply with 8.2.5.2.

Findings include:

1.Corrected 04/19/13

2. In the morning of 07/19/2012, North Tower Wing, First Floor - The survey finds that the Southwest stair does not discharge directly to the outside in accordance with 7.7.1. Multiple floors use and are provided with two hour horizontal exits. These horizontal exits are not continuos two hour fire barriers from foundation to roof in accordance with 7.2.4.3. The South West Stair 1AS3 serving North Tower Wing and Concourse Wing discharges into the interior of the Concourse Building which does not provide a complete fire separated exit path to the outside in accordance with 7.2.4.3.1 Exception (c).

3.Corrected 04/19/13

4. Deleted 04/19/13

A) Based upon random observation, the surveyor finds that during fire alarm testing conducted on 07/19/20 and 07/20/1 with multiple hospital engineering and management staff present, doors with exit signs and magnetic locking devices failed to release the locking devices in accordance with 7.2.1.5 and/or 7.2.1.6. Based upon the number of locations above where locked failed to release, similar condition are expected on multiple floors and multiple buildings or wings throughout the facility. This deficiency is cited for all doors with an exit sign above the door and any kind of magnetic locking device (except for the magnetic locking devices installed that were observed to release from fire alarm activation on some stair doors.)

Examples include but are not limited to:

1) North Tower 11th Floor (OB): The exit access corridor between the southwest stair and the O B Unit has a pair of cross corridor control doors with magnetic locking devices that do not comply with NFPA 101

a) The doors did not unlock from activation of the fire alarm system on this floor and upon activation of the fire alarm in an adjacent zone.

b) The blue door unlock pull station device mounted on the wall does not comply with the requirements of 7.2.1.6.2 (it is not a "push to exit" device) and the operation of the pull device does not comply with 7.2.1.5 (it requires special knowledge to operate).

2) 10th floor, North Tower, delayed egress cross corridor doors did not disengage to a manual operation.


3) North Tower 8th Floor (Peds): The exit access corridor between the southwest stair and the Peds Unit has a pair of cross corridor control doors with magnetic locking devices that do not do not release from activation of the fire alarm sytem.

4) 7th Floor Parkview: The east stair door has a magnetic locking device, During fire alarm testing on the morning of 7/20/12, and in conjunction with testing without the fire alarm system, the surveyor observed that the locking device on the door has a slight "hitch" in it operation and that it did not always immediately release upon activation of the fire alarm system.

5) 4th floor Parkview LDRP, delayed egress cross corridor doors did not disengage to a manual operation.

6) 1st Floor Center Building - pair of doors near E D Nurse's Station: these doors have exit designations and magnetic locking devices that did not release from fire alarm activation

7) 1st Floor Center Building - pair of doors at the south end of the Emergency Department: these doors have exit designations and magnetic locking devices that did not release from fire alarm activation.

B) Multiple floors and multiple buildings or wings: The blue door unlock pull station device mounted on the wall does not comply with the requirements of 7.2.1.6.2 (it is not a "push to exit" device) and the operation of the pull device does not comply with 7.2.1.5 (it requires special knowledge to operate).

Failure that release locking devices during a fire emergency will delay evacuation of patients when necessary during a fire emergency.

End


16339

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 18.2.1. The North Tower Infill built in 2007 was surveyed under Chapter 18 of NFPA 101 2000. This condition could affect any patients, as well as any staff and visitors within the facility and could cause a delay of evacuation during a fire particularly for any staff, patients and visitors that are not intimately familiar with the facility

A. North Tower Wing, 9th Floor, NICU the surveyor determines that the required exit access corridors from the elevator foyer lobby to the NICU Suite has only one path of egress. The corridor may not terminate at a Suite. The exit sign above the control doors identify a path into a suite that is not permitted and the corridor is a 50 feet dead end corridor.

B. Corrected 04/19/13

C. North Tower Wing, First Floor - Designated exit path from the Conference Room 1600 passes thru the required Stair 1AS4 which serves Lower Level or continues beyond level of exit discharge is not provided with interrupter gate to comply with 7.7.3.

D. Based on random observation during the survey walk-through, not all designated exits are properly maintained to ensure the dependability of the method of evacuation selected to comply with 18.7.3.

Findings include:

1. 11:00AM, 07/17/2012, North Tower Wing: Designated exit path doors equipped with magnetic hardware and secured with locking devices were not available to pass through in case of fire or other emergency situation to comply with 18.7.3 and 7.2.1.6.2 Subpart (b). Locations include: 11th Floor Post Partum and 10th Floor LDR patients. This deficiency could affect LDR and Post Patients patients because this locked door is not being maintained, and tested that this exit egress door is available especially under fire conditions at any time.







20224

Based on random observation and staff interview during the survey walk-through, not all exit or exit access doors are arranged so that exits are readily accessible at all timesto comply with 19.2.1 and Chapter 7. These deficiencies could affect all patients, staff and visitors in the facility, by preventing occupants from reaching an exit from the building.

Findings include:

A. Afternoon of 07/19/12, the tunnel connection at the North Clinic lacks a designated exit sign into the Clinic. This produces a dead end corridor condition of excessive length and does not comply with 19.2.5.9.

B. Morning of 07/18/12, Parkview, all occupied levels 2nd - 8th floors contain a dead end corridor condition of approximately 70 feet. The dead end extends from a pair of cross corridor doors locked against egress within a south end corridor to the corridor where Rogers connects to Parkview.

04/19/13: The PoC for the item references attachments that are not attached to every PoC. A narrative indicating how each will be corrected is not provided.Corrected 04/19/13

C. Afternoon of 07/17/12 8th floor Parkview CVCU; the direction of egress, is indicated by an exit sign located above the inactive leaf of a pair of cross corridor exit access doors.

Based on random observation during the survey walk through the surveyor noted numerous designated suites which did not appear to comply with 18.2.5. The North Tower 2nd Floor was renovated in 2007 therefore this wing has been evaluated under Chapter 18. Four designated suites do not comply.

Findings include:

A. North Tower Wing, 2nd Floor, OR / Recovery Suites: The surveyor finds that multiple suites identified as S1, S2, and S3 are probably not suites and each suite lacks access to two remote exit access corridor doors in accordance with 18.2.5.3. All three suites must pass through adjoining suites to reach a corridor door. These suites do not comply with 18.2.5.8. The two hour fire barriers that are installed between the suits do not comply with 7.2.4.3.1; the fire compartments are part of the adjacent fire compartment. The two hour fire barriers define the boundaries between suites only and not horizontal exits.

B. North Tower Wing, 2nd Floor, OR Suite S3 identified 12,042 s.f. does not comply with 18.2.5.7 for the maximum allowable square footage for a non sleeping room suite, the maximum permitted is 10,000 square feet.

Failure to maintain suite boundaries and provide access to corridors doors from the suites will increase the travel distance to a corridor for horizontal evacuation during a fire emergency.

04/19/13: The PoC does not clearly indicate how and when the above items will be corrected and the RJA plans referenced are not attached to every PoC. The HVI project will be completed and occupied by 07/31/13. A detailed narrative/corrective action is not provided for each suite and/or for each part of Item A and Item B above. A detailed phasing schedule is not provided. Any changes will likely require submittal as a project. Compliance of th recently completed TAVR OR Project (Project 9709) will be confirmed with the correction of K042. What OR Project is proposed?

End










20224


Based on random observation and staff interview during the survey walk-through, not all designated suites are provided with exits in accordance with 19.2.5. Intervening rooms within a suite allow for a delay in becoming aware of a fire and to reach an exit access corridor. This condition could affect patients, visitors and staff on this floor level.

Findings include:

A. Afternoon of 07/18/12 3rd floor Rogers, Inpatient Therapy Services and Rehabilitation, deemed a suite by the facility, lacks the required arrangement of a means of egress to an exit access door and does not comply with 19.2.5.1 exception #2. Patient sleeping rooms have two intervening rooms to traverse in order to gain access to an exit access corridor. An example location is the semi-private room #3576 (as shown on the Life Safety floorplan) which must travel through room # 3377 and corridor #3385.

A) Based on random observation the surveyors find that designated two hour fire barriers are not installed or maintained in accordance with Chapter 8 of NFPA 101:

Findings include

1) The Basement Level Rogers Utility tunnel at the sign shop has a pair of 90 minute fire doors that lead the the Rogers east/west corridor. The two hour wall at this location has multiple penetrations that are not sealed for two hour construction.

2) The Basement Level Rogers corridor has a designated two hour corridor wall opposite the West Stair. There is an opening in the wall at ceiling height with a fire damper that is not installed in accordance with NFPA 90A. The fire damper is partially closed and is buckled at the base of the damper. Some type of penetration under the damper is not installed to maintain the two hour fire barrier and/or the corridor wall as a smoke tight barrier in accordance with Chapter 8 of NFPA 101 and/or 19.3.6.2.1.

3) Corrected 04/19/13

4) Corrected 04/19/13

5) 2nd Floor Center Wing - there is a designated two hour fire barrier between the Center Wing and the North Clinic. There is a pair of 90 minute cross corridor doors at this two hour fire barrier. The two hour barrier does not comply with 8.2.3.2.4.

a) Multiple penetrations above the ceiling at this location are not sealed for two hour construction.

b) Ductwork penetrates the fire barrier above the ceiling and does not comply with NFPA 90A; no fire dampers or fire damper access panels were found

6) 3rd Floor Center Wing - Southeast Mechanical Room. The surveyor notes that that this space appears on plans to be part of the North Clinic at the 2nd and 3rd Floors. It is part of the Center Wing and is separated from the North Clinic by designated two hour fire barriers.

a) The 3rd Floor door to the Mechanical room is not a 90 minute fire door.

b) Two duct penetrations above the 3rd Floor corridor door above the ceiling have fire dampers; however, there is a void in the fire wall between the two ducts and the fire dampers are not installed in accordance with NFPA 90A

Failure to maintain fire barriers will allow smoke and fire to spread throughout the building more quickly in a fire emergency.

End


16339

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers as shown on the Life Safety drawings are constructed or maintained as fire resistive assemblies as required by NFPA 101, 8.2.3.2.4.1&2. These deficiencies could affect all persons in the facility, by preventing the barriers from providing the intended separation protection.

Findings include: See also K-042

A. At 10:55AM, 07/18/2012 North Tower Wing 2nd floor Designated 2 hour fire separation wall also identified two hour horizontal exit on the drawings, walls above the ceiling do not form a complete two hour barrier by the exit access cross corridor door leading to the OR Suites near the Stair 2AS3.

04/19/13: The PoC for the above item does not clearly identify how this was resolved. Was the two hour designation that is clearly identified on the survey plans changed? We note that the cross corridor doors at this location are not 90 minute fire doors. How was the above item corrected?

B. At 1:30PM, 07/18/2012 North Tower Wing 2nd Floor OR Based on observation all double egress doors to the the designated two hour fire rated horizontal exit which is also the OR suite boundary are not 90 minute fire doors with U L Labels and these fire doors are not self closing. One door was observed to have only a 45 minute rating.

C. In the afternoon, on 07/18/2012 North tower 2nd Floor Designated 2- hour separation
wall near the OR Pharmacy was observed with pipes and conduits penetration above the ceiling that are not fire sealed. The door to the pharmacy, which is part of the fire separation wall is only 20 minute rated and does not comply with 8.2.3.2.3.1(1)


20224

Based on random observation and staff interview during the survey walk-through, not all 2-hour barriers are constructed in accordance with 8.2.2.2. These deficiencies could affect all persons in the facility, by preventing the barriers from providing the intended separation protection.

Findings include:

A. Morning of 07/20/12, 3rd floor, North Clinic at the bridge, the designated 2-hour fire barrier (as shown on the Life Safety floor plans) does not carry the minimum fire resistance rating due to the wall construction above the pair of cross corridor doors contains an unprotected structural steel member not fire proofed to comply with 19.1.6.2 and large gaps within the wall at both ends of the door frame.

B. Afternoon of 07/19/12, North Clinic at the tunnel, the designated 2-hour fire barrier (as shown on the Life Safety floor plans) does not carry the minimum fire resistance rating due to the wall construction above the pair of cross corridor doors that contains an unprotected structural steel member not fire proofed to comply with 19.1.6.2.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. North Tower Wing, 11th Floor, Nursery Corridor - The egress path was observed to not be properly identified in accordance with 7.10.1.1. No exit sign was observed to direct building occupants into the nearest exit.

B. North Tower Wing, 2nd Floor, OR - Exit sign is not provided by the OR lounge to identify egress paths as required by 7.10.1.1.

C. North Tower Wing, 1st Floor, Digestive Health Procedure Suite - The Suite's aisles lack exit signage to direct occupants to the nearest exit.

Based on random observation during the survey walk-through, not all exit and directional signs provide a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. The deficiency could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building. Location include:

A. North Clinic Building, First Floor - The directional exit sign in the North Clinic East near the Volunteer Office was observed pointing in wrong direction which does not direct occupants toward an exit to comply with 7.10.1.1.

A) Corrected 04/18/13

B) Written Fire Plan: The provider has indicated that the building fire alarm system does not activate globally but instead activates by zone of activation and in all zones adjacent to the zone of activation. The provider lacked specific information that identifies all fire alarm zones and sprinkler zones. This information is necessary to determine which zones are adjacent to the zone of activation and is necessary to determine whether fire alarm zones, sprinkler zones match to building separations, areas or wings that are defined by fire barriers, smoke barriers, suite boundaries, etc. All components and panels of the fire alarm and sprinkler system report to a monitoring location in the E R Security Room which is constantly attended. For any fire event, in addition to automatic notification to specific zones, an overhead announcement is made (manually initiated) that identifies the location of the fire to all portions of every building or wing. The written fire plan for the Hospital does not acknowledge the above conditions and does not clearly identify the staff response for fire in that area of activation, for a fire in the adjacent zones and for a fire in the zones where the fire alarm does not automatically announce a fire (which could include two zones away from the fire and also remote locations).

Lack of a specific and detailed plan for the conditions identified above could result in a delayed response or inadequate response in a fire emergency.

C) Corrected 04/18/13


End

A) Corrected 04/18/13

B) Written Fire Plan: The provider has indicated that the building fire alarm system does not activate globally but instead activates by zone of activation and in all zones adjacent to the zone of activation. The provider lacked specific information that identifies all fire alarm zones and sprinkler zones. This information is necessary to determine which zones are adjacent to the zone of activation and is necessary to determine whether fire alarm zones, sprinkler zones match to building separations, areas or wings that are defined by fire barriers, smoke barriers, suite boundaries, etc. All components and panels of the fire alarm and sprinkler system report to a monitoring location in the E R Security Room which is constantly attended. For any fire event, in addition to automatic notification to specific zones, an overhead announcement is made (manually initiated) that identifies the location of the fire to all portions of every building or wing. The written fire plan for the Hospital does not acknowledge the above conditions and does not clearly identify the staff response for fire in that area of activation, for a fire in the adjacent zones and for a fire in the zones where the fire alarm does not automatically announce a fire (which could include two zones away from the fire and also remote locations).

Lack of a specific and detailed plan for the conditions identified above could result in a delayed response or inadequate response in a fire emergency.

End

A) Corrected 04/19/13

B) Written Fire Plan: The provider has indicated that the building fire alarm system does not activate globally but instead activates by zone of activation and in all zones adjacent to the zone of activation. The provider lacked specific information that identifies all fire alarm zones and sprinkler zones. This information is necessary to determine which zones are adjacent to the zone of activation and is necessary to determine whether fire alarm zones, sprinkler zones match to building separations, areas or wings that are defined by fire barriers, smoke barriers, suite boundaries, etc. All components and panels of the fire alarm and sprinkler system report to a monitoring location in the E R Security Room which is constantly attended. For any fire event, in addition to automatic notification to specific zones, an overhead announcement is made (manually initiated) that identifies the location of the fire to all portions of every building or wing. The written fire plan for the Hospital does not acknowledge the above conditions and does not clearly identify the staff response: for fire in that area of activation, for a fire in the adjacent zones and for a fire in the zones where the fire alarm does not automatically announce a fire (which could include two zones away from the fire and also remote locations).

Modified 04/19/13: The Provider has indicated that the fire alarm chimes and strobes activate globally; however they have not defined in writing which buildings are areas are included under global activation. The provider has indicate that a staff response is initiated in the zone of activation and in all adjacent zones. However, the fire alarm system and sprinkler system may not be designed or installed to annunciate the location of a fire automatically. The fire alarm and sprinkler zones may not match the building compartmentation as zones and only way to identify where the fire is in many of the zones is from a manually activated P A announcement. Use of the manually activated P A System is acceptable as a secondary protocol and for interim measures, only. It does not comply with NFPA 72 requirements for occupant notification in Health Care.

C) The survey was conducted using Life Safety Plans that were provided by the Hospital. These plans were dated 2010 and were created by SSR. The following deficiencies identify conflicts between the Life Safety Code (NFPA 101 - 2000) and these Life Safety Plans

1) Center Wing/North Clinic: The plans identify a two hour fire separation between the Center Wing and the North Clinic on the 1st, 2nd and 3rd Floors. The Life Safety Plans identify "exits" through these two hour barriers on the 1st, 2nd and 3rd Floors. From random observation, the surveyors observed exit signs above the 90 minute fire doors at these same locations.

The only exit designation that can be used at these locations is as a horizontal exit. However, the designated exits do not comply with the rules of horizontal exits under 7.2.4.3.1 (NFPA 101). The two hour fire separation between the Center Wing and the North Clinic does not continue through the Basement Level.

Revised 06/07/13: The above locations may have two hour barriers that are not horizontal exits which means that travel distance cannot be measured to them but must continue through them to a legitimate exit.

2) Corrected 04/19/13

D) (New 04/19/13) Based on an onsite review of RJA Life Safety Plans dated 01/31/13, the surveyor finds the life safety components are missing or are not identified.

1) 1st Floor Exit Stair 1AS1 is not shown with two hour fire rated enclosures and the 1st Floor (new) discharge for this stair is not identified on all plans as an Exit Passageway.

2) 3rd Floor Concourse Level - Mechanical Room with Kitchen Exhaust Ducts. The Life Safety Plans show a shaft enclosure at this 3rd Floor location where no shaft exists on this level.

End

A) The surveyor notes that the Hospital has personnel that work eight hour shifts and some personnel that work twelve hour shifts. Based upon a review of fire alarm documentation for the previous 12 months in multiple buildings, 07/20/12 with the facility safety officer, the surveyor finds that the provider conducts and observes fire drills in the zone of activation and typically in two adjacent zones.

1) The provider lacked specific information that identifies each zone and the boundaries of each zone that is being included in the zones to be observed during a fire drill.

2) Corrected 04/18/13

04/18/13: The item will remain open and documentation of future drills will continue to be revised as long as interim life safety measures are required.

End

A) The surveyor notes that the Hospital has personnel that work eight hour shifts and some personnel that work twelve hour shifts. Based upon a review of fire alarm documentation for the previous 12 months in multiple buildings, 07/20/12 with the facility safety officer, the surveyor finds that the provider conducts and observes fire drills in the zone of activation and typically in two adjacent zones.

1) The provider lacked specific information that identifies each zone and the boundaries of each zone that is being included in the zones to be observed during a fire drill.

2) Corrected 04/18/13

4/18/13: Fire drill documentation to be reviewed also on future surveys.

End

A) The surveyor notes that the Hospital has personnel that work eight hour shifts and some personnel that work twelve hour shifts. Based upon a review of fire alarm documentation for the previous 12 months in multiple buildings, 07/20/12 with the facility safety officer, the surveyor finds that the provider conducts and observes fire drills in the zone of activation and typically in two adjacent zones.

1) The provider lacked specific information that identifies each zone and the boundaries of each zone that is being included in the zones to be observed during a fire drill.

4/19/13: Although the above item is essentially the same citation that is part of K048, the information required is not currently available and the correction date needs to be revised.

2) Corrected 04/19/13

3) Corrected 04/19/13

4) Corrected 04/19/13

The surveyor notes that the provider is conducting two fire drills per quarter per shift. Fire drill documentation will continue to be reviewed for as long as Interim Life Safety Measures are required.

A) From random observation and testing the surveyors find that the fire alarm system is not installed and maintained in accordance with NFPA 72. Multiple devices connected to the fire alarm system failed to respond/activate/de-active upon activation of the fire alarm system in the same zone and/or in adjacent areas where the zone boundaries are not defined.

Examples include:

1) Locking devices installed on doors on multiple floors and multiple wings or buildings failed to unlock from activation of the fire alarm system during testing on the afternoon of 7/19/12 and the morning of 7/10/12. This deficiency is also cited under K038 for conditions relative to unlocking devices from fire alarm activation. The provider also failed to detect and abate this condition during quarterly or annual fire alarm testing in accordance with NFPA 72.

2) Multiple auto-open functions and hold-open devices installed on doors on multiple floors and multiple wings or buildings failed to unlock from activation of the fire alarm system during testing on the afternoon of 7/19/12 and the morning of 7/10/12. This deficiency is also cited under K018 and K021. The provider also failed to detect and abate these conditions during quarterly or annual fire alarm testing in accordance with NFPA 72.

3) Basement Level Nutrition Bulb Room - this room provides access to an electrical room with Transfer Switch A-3EOR. A smoke detector installed three feet below the deck above is not installed in accordance with NFPA 72.

Failure to test and maintain devices and components that are tied to the fire alarm system will result in delayed responses by life safety systems and personnel in a fire emergency.

End


20224

Based on random observation and staff interview during the survey walk through, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

A. Afternoon of 7/19/2012, during a test of the fire alarm system, the first floor Concourse (Breezeway) lacks functioning audible notification devices from activation of the system in adjacent zones.

K051 - The facility does not comply with NFPA 72 - 1999 and 21.3.4.1 of NFPA 101 - 2000.

A) From random observation, the surveyor finds that the fire alarm system that serves the clinical spaces, the Surgery Center and the Recovery Center are not installed, tested and maintained in accordance with NFPA 72-1999. Findings include:

1) The main fire alarm panel is located in the adjacent Clinic Building. (information only)

a) Corrected 04/17/13.

b) Corrected 04/17/13

c) Corrected 04/17/13.

2) Trouble signals from the fire alarm system and supervisor signals from the sprinkler system are not transmitted to both the Surgery Center and to the Recovery Care Center, at a constantly attended location in each. (NFPA 72-1999, NFPA 101-2000, section 9.6.7.5 and 9.7.2.1, NFPA 72-1999, section 7.7.2.1).

04/17/13: Although a visual signal is provided, trouble conditions and supervisory conditions do not send an audible signal to a constantly attended location in accordance with the referenced standards.

3) Documentation for testing, maintenance and service of the fire alarm system was not immediately available and is not maintained on site for the past 12 months, in accordance with NFPA 72.

04/17/13: The above item will remain open until all deficiencies under K051 are corrected.

4) (Revised 04/17/13): Documentation for testing, maintenance and service of the sprinkler system was not immediately available and is not maintained on site for the past 12 months in accordance with NFPA 25.

a. Although other documents may identify complying testing and maintenance, such documents are not identified as the "annual testing and maintenance" that is required by NFPA 25. The annual inspection dated 10/15/12 is left blank for the section provided for the annual main drain test. Also, the section for testing of gauges is marked NA without indicating when they were last tested or replaced.

b. Testing documentation for two devices on 2/18/13 indicates that the form is for a "Main Drain and Inspectors Test". The documentation is inadequate as the quarterly flow test for two of two inspectors test valves (that are installed to simulate the flow of one sprinkler ead). The documentation provided is confusing at best but does not identify a test of an inspector's test valve and sprinkler flow switch (with the location of the inspector's test valve clearly identified). The documentation is more likely a test of two of two main drain valves at the same location without explanation: of what they are, why there are two at the same location and why the test was not done as part of the annual inspection of 10/15/12.

c. Although two pipes and valves are identified in a Lower Level Sprinkler System Room B112A as "Drains", neither is identified as a Main Drain.

d. The surveyor found no evidence of quarterly flow testing of two of two inspector' test valves that include the location of each valve along with the time from water flow initiation to activation of the fire alarm with the inspector's test valve fully open.

End

A) Based on random observation through the Hospital, the surveyors find the sprinkler system is not installed and maintained in accordance with NFPA 13. This includes sprinkler system deficiencies that are identified on quarterly sprinkler system inspection reports.

Examples include but are not limited to:

1) Corrected 04/19/13
2) Corrected 04/19/13
3) Corrected 04/19/13
4) Corrected 04/19/13
5) Corrected 04/19/13
6) Corrected 04/19/13

7) Basement Level Rogers South Mechanical Room has an electrical room that lacks sprinkler protection.

8) Corrected 04/19/13
9) Corrected 04/19/13
10) Corrected 04/19/13
11) Corrected 04/19/13
12) Corrected 04/19/13
13) Corrected 04/19/13

14) 1st Floor Center Wing Walgreens Space - The shelving in the back of this space is closer than 18" below the sprinkler heads installed. Some of the sprinkler heads are obstructed and not installed in accordance with NFPA 13 (obstructions and/or sprinkler head spacing does not comply).

15) Corrected 04/19/13
16) Corrected 04/19/13
17 Corrected 04/19/13

End


14416


By direct observation on the morning of 7/17/12 & 7/18/12, while in the company of the Central Plant Supervisor, the surveyor find not all building space are protected by a fire suppression system. The unprotected spaces listed below are examples and the lack of protection is not limited to only these spaces:
A. Parkview:
1. Corrected 04/19/13
2. Corrected 04/19/13
3. Corrected 04/19/13

B. North Tower:
1. 4 th Floor Patient toilet rooms 4118 & 4130. 4/19/13: Access was not available; rooms was occupied by isolated patient - provide photographic evidence.
2. Corrected 04/19/13



16339


A. Corrected 04/19/13

B. Corrected 04/19/13

C. Corrected 04/19/13



17659

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

A. Five of five fire pump locations were surveyed.

1. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7 for any of the fire pumps. 4/18/13: The provider has documentation for testing of only two of four points

2. Corrected 04/19/13

3. The transfer switch for the fire pump in the Parkview Wing is not located in the pump room as required by NFPA 20-6-6.4.





20224

Based on random observation and staff interview during the survey walk through not all portions of the building are sprinkler protected. This could result in delayed activation of the sprinkler system. This condition may affect patients, staff and visitors within the building.
Findings include:

A. Morning of 07/17/2012 5th floor Parkview mechanical room, sprinkler heads were observed below a duct greater than 48 inches in width in which one head was not in the correct position. This condition does not comply with NFPA 90A 1999 1-3.1 (1) and (2).

B. Morning of 07/18/2012, The facility failed to provide fire suppression for the following areas:

1. Corrected 04/19/13

2. Modified 04/19/13: 9th floor Parkview,
Mechanical room #911 (as shown on
Life Safety floor plan) lacks sprinkler
protection below ductwork greater than
48 inches in width. Example location -
entry located north of corridor #910
contains an aisle to the left which dead
ends and is surrounded by ductwork
overhead.
04/19/13: Sprinkler protection was not
provided at the north end of S-2

3. 4th floor Rogers, room adjacent to room
# 4465 and #4466 lacks sprinkler
coverage.

4. 6th floor Parkview, patient room closets
(floor to ceiling) lack sprinkler coverage,
example location room #6616 (as shown
on Life Safety floor plan). The closest
sprinkler head is located more than 5
feet away beyond the privacy curtain.

5. Corrected 04/19/13

A) Based on document review of sprinkler maintenance and testing for reports dated 5/14/20012, the surveyor finds that the sprinkler system in multiple buildings is not being tested, serviced and maintained in accordance with NFPA 25 - 1999.

Examples include:

1) The sprinkler inspection report dated 5/14/2012, for the North Clinic sprinkler system identifies eight deficiencies identified in the report that include previously cited main drain deficiencies and also deficiencies with tamper switches that did not report to the fire alarm and sprinkler heads that were not installed in accordance with NFPA 13.

2) The sprinkler inspection report dated 5/14/2012, for the North Clinic sprinkler system identifies under item "4 c" that visible sprinkler piping is not in good condition. There was no further explanation for this condition.

The sprinkler system may not perform correctly in a fire emergency if it is not tested and maintained in accordance with NFPA 13/NFPA 25.

End

A) Based on document review of sprinkler maintenance and testing for reports dated 5/14/20012, the surveyor finds that the sprinkler system in multiple buildings is not being tested, serviced and maintained in accordance with NFPA 25 - 1999.

Examples include:

1) The sprinkler inspection report, dated 5/14/2012, for the North Clinic sprinkler system identifies eight deficiencies that include previously cited main drain deficiencies and also deficiencies with tamper switches that did not report to the fire alarm and sprinkler heads that were not installed in accordance with NFPA 13.

2) The sprinkler inspection report, dated 5/14/2012, for the North Tower Wing sprinkler system identifies eighteen deficiencies at the end of the report that include devices that failed to report to the fire alarm system and sprinkler heads that are not installed in accordance with NFPA 13.

3) The surveyor observed similar reports for other wings and buildings.

The sprinkler system may not perform correctly in a fire emergency if it is not tested and maintained in accordance with NFPA 13/NFPA 25.

End


16339

Based on observation the automatic sprinkler system is not inspected, maintained, and tested in accordance with NFPA 25. This condition can lead to a poorly maintained system which can fail during a fire emergency affecting all patients, staff and visitors.

Findings include:

A. Corrected 04/19/13

B. Corrected 04/19/13

C. On random observation the surveyor finds sprinkler heads with missing escutcheon plates as required NFPA 25 1998 2-4.1.8. Locations include:

1. North Tower Wing, Third Floor near the Tower Elevator by Exit Stair

2. North Tower Wing, 2nd Floor - Phase 2 Recovery in the Soiled Utility Room

A) Based on document review of sprinkler maintenance and testing for reports for the previous six months, the surveyor finds that the sprinkler system is not being tested, serviced and maintained in accordance with NFPA 25 - 1999.

1) The sprinkler testing report dated 5/02/12 for the Mills Breast Cancer Center dry pipe system for the Basement Level MRI does not clearly identify an internal inspection of the dry pipe valve and/or does not indicate when this was last done. The report indicates that the date of the last full trip test is unknown and does not indicate why a full trip test was not conducted at the time of this report.

The sprinkler system may not perform correctly in a fire emergency if it is not tested and maintained in accordance with NFPA 13/NFPA 25.

End

A) Based on random observation, the surveyors find that mechanical systems are not installed, tested and maintained in accordance with NFPA 101 and NFPA 90A:

Findings include:

1) Corrected 04/19/13

2) Basement Level CDU Mechanical Room (across from Cafeteria): Two ducts penetrate the fire rated floor above. Fire dampers were not found in accordance with NFPA 90A.

3) Basement Level Rogers and Center Wing: There is a north and south Mechanical Room in the east side of the building. One or both rooms are open to a vertical shaft enclosure. These mechanical rooms are defined on the Life Safety Plans with two hour fire barriers.

a) Multiple ducts penetrate these two hour
barriers without fire dampers and do not
comply with NFPA 90A.

4) Basement Level Rogers and Center Wing: The north and south Mechanical Room in the east side of the building has a tee shaped room in the middle of the Mechanical Rooms that is part of an air intake plenum and air intake shaft that extends to the 3rd Floor Roof above.

a) All portions of the air intake shaft
enclosure on multiple floors are not
identified as fire rated enclosures on the
Life Safety Plan. Not enough
information is not provided to
demonstrate how this shaft complies
with NFPA 101 and NFPA 90A The
shaft location is missing on the 1st and
2nd Floors.

b) These air intake shaft are required to be
enclosed from the Basement Level to the
roof (minimum - one hour shaft
enclosure). Fire dampers were not found
at air intake louvers or openings in the
Basement Level Mechanical Room in
accordance with NFPA 90. Fire
dampers were not found on all floors
where ducts or openings penetrate this
shaft.

c) A fire rated shaft enclosure was not
found at the 1st Floor (with multiple
sealed penetrations into the shaft. Also,
The door to this shaft at the 1st Floor
is not a fire rated B Label fire door
and it lacks self closing hardware.

d) No fire rated shaft enclosure was found
on the 2nd Floor. The shaft appears to
be open to adjacent ceiling cavities,
assess doors are not fire rated and ducts
lack fire dampers.

5) There is a 1st Floor Mechanical Room on the north side of the west Wing of the North Clinic. The mechanical space is separated from portions of the 1st Floor of the North Clinic and the Center Wing of the Hospital by two hour fire barriers. However, in the Basement Level the North Clinic is only separated from the Center Wing by a one hour smoke barrier. This does not constitute a building separation. Multiple duct penetrations through the 1st Floor two hour fire barriers (3 ducts at the north wall and 2 ducts at the south wall) lack fire dampers in accordance with NFPA 90A.

6) 1st Floor Center Wing - The is a large duct shaft in the Northwest corner of the Walgreens Pharmacy. The shaft has multiple ducts with fire dampers at the floor. The access panel for one of the ducts was left open. Access to this shaft for inspection and maintenance is through an shaft access door that is three feet above the floor and that is mostly blocked by a shelf in the Walgreens space. Access to the fire dampers was not provided in accordance with NFPA 90A. An inspection of the fire dampers and shaft could not be conducted; access could not be provided.

Failure to maintain vertical openings and failure to install and maintain fire dampers where required will allow fire to spread from floor to floor in a fire emergency.

End




20224

A. Corrected 04/19/13

A) Corrected 04/19/13


14416


North Tower:
By direct observation in the 3rd Floor Mechanical Room on the morning of 7/17/12 while in the company of the Central Plant Supervisor, the surveyor finds the facility failed to install the kitchen grease hood ventilation systems in compliance with NFPA 96, 1998:

1. Corrected 04/19/13

2. The four grease laden vapor exhaust ducts, for the Kitchen Hoods, from the enclosing shaft to the utility fan sets (Fan Nos. 21, 22, 23 & 24) and from the fan sets to the exterior are not separated with rated construction from other parts of the facility's mechanical systems located within this mechanical room (i.e. air handlers, pumps and compressors). The ducts were covered with thermal insulation. (NFPA 96, 1998, 4-7.1) 4/19/13: A phasing schedule which includes a project submittal is not included with the PoC for this item

3. Corrected 04/19/13

A) Corrected 04/18/13




16339


A. Corrected 04/18/13



20224


Based on random observation and staff interview during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. or 39.2.3.2. These deficiencies could affect any patients, staff, or visitors attempting to utilize these corridors under emergency conditions by impeding egress.

Findings include:

A. Corrected 04/18/13

B. (Modified 04/19/13): 8th floor Parkview, CVCU (Cardio-Vascular Critical Care Unit which is not a designated suite) Through staff interview, and observation there is no designated clean utility and all materials are stored on multiple shelving units within the centrally located nurses station. This condition also does not comply with 19.3.2.1 whether it is part of a corridor or within a suite.

C. (Modified 04/19/13): Afternoon of 07/18/2012, 7th floor Parkview, ICU (which is not a designated suite) Through staff interview, and observation there are numerous materials stored on multiple shelving units and in many Pixis Units within the centrally located nurses station. This condition also does not comply with 19.3.2.1 whether it is part of a corridor or within a suite.


D. Afternoon of 07/17/12, 2nd floor, Concourse Stage I Recovery, contains numerous materials stored throughout the exit access corridor between Recovery and Surgery (adjacent to the Doctor's Lounge). On 4/19/13, the surveyor observed two refrigerators and multiple steel shelves in this corridor near the doors to Recovery. These items reduce the required 8 foot width of the exit access corridor.

E. Corrected 04/19/13

A) Based on random observation the surveyor finds that oxygen tanks are not stored in accordance with NFPA 99-1999.

1) 1st Floor Center Wing - There is a storage room near the Northwest Stair. On 7/18/12, this room had multiple oxygen tanks stored closer than five feet from all combustibles.

2) Corrected 04/18/13

Parkview 2nd Floor Suite 8 as shown on the Life Safety documents provided:

By direct observation the surveyor finds not all medical gas zone valves are labeled to reflect the outlets/inlets they serve (NFPA 99, 1999, 4-3.1.2.14 (b) 3) and in some cases depending on correct labeling the valve location may not meet NFPA 99, 1999, 4-3.1.2.3 in that the zone valves are not separated by an intervening wall from the outlets/inlets they serve.

K106 - The facility does not comply with the 1999 Editions of NFPA 70, 99, 110 and NFPA 101 - 2000, Section 21.2.9:

A) The Surgery Center and Recovery Care Center have a shared emergency power system that is supplied from an exterior, pad mounted, diesel generator. This generator is not installed to comply with NFPA 70. NFPA 99, NFPA 110 and/or OSHA.

1. Corrected 04/17/13

2. Corrected 04/17/13

3. Corrected 04/17/13

4. Corrected 04/17/13

5. The emergency power electrical distribution system for the Surgery Center and for the Recovery Care Center has two transfer switch. The emergency electrical service does not have three separate branches (with panels and circuit identification) for equipment branch, critical branch and life safety branch, as required by NFPA 70-517 - 1999 and NFPA 99 - 1999. The same requirements were found in NFPA 70 as far back as the 1970 Editions. The provider lacks detailed information identifying how the facility complies.

04/17/13: The above item was not corrected in accordance with the last submitted PoC. The plans for the correction work are not accurate. One new transfer switch and two new emergency distribution panels were installed. The transfer switch and panels have no panel identification and the panels have no circuit identification.

6. Corrected 04/17/13



End

A) K130 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.

1) The facility does not comply with NFPA 101 and lacks adequate interim measures for all cited deficiencies.

4/17/13: Interim measures will be reviewed until all corrective actions have been completed.

B) Based on random observation the surveyor finds that there is a bag-in-box beverage system in a room in the Basement Level Concourse Wing Kitchen. Six of six large pressurized vessels were not secured to the wall with chains that were provided. This installation is not maintained to comply with NFPA 55 -1985 Edition, Section 6-6.

04/19/13 The above item was not corrected

C) Corrected 04/18/13

A) K130 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.

1) The facility does not comply with NFPA 101 and lacks adequate interim measures for all cited deficiencies.

The above item will remain until all deficiencies are corrected in this building.

Based on random observation during the survey walk-through the building emergency the surveyor finds that the emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517.

Findings include:

1. Life Safety Panels such as XLA8A, XLA7A, XLA6A in the electrical closet on each floor of the North Tower are all serving loads that include: nurse call, comm room receptacles, hall receptacles, time clocks, cameras and cart lifts that should be served by other branches to meet the requirements of NFPA70, Section 517-32 through 34.

2. The Parkview Wing of the main building has Life Safety and Critical Panels in the electrical closets on each floor, including the elevator equipment room that are serving loads that should be served by other branches in accordance with NFPA-70, Section 517-32 through 34. Panels R-1C-8RE1 and R-1C-7RE1 are examples of critical panels that are serving fire alarms that should be served by the life safety panels, and life safety panels L-1S-8RE and L-1S-7RE, and the life safety panels on each floor are serving loads such as nurse call, and room receptacles that should be served by critical panels.

3. The Rogers Wing of the main building has a single emergency panel on each floor serving a mixture of life safety, critical, and in some cases equipment which does not meet the requirements of NFPA-70, Section 517-30 through 34.

4. The Center Wing of the main building had critical panels XCD3A, and XCD1B serving med gas alarms that are required by NFPA-70, Section 517-32 to be served by the life safety branch, and life safety panel XLD2A was serving the nurse call system which is required by NFPA-70, Section 517-33 to be served by the critical branch of the emergency power system.

A) Based on random observation throughout multiple floors and multiple buildings or wings, the surveyors find that data cables above the ceiling area supported by ceiling tiles, sprinkler piping, conduit, ductwork, etc. above ceilings.

The data cables are not supported independently in accordance with NFPA 70 1999 800-52(e). The non-complying supporting elements above ceilings (ceiling tiles, conduit, ducts, sprinkler piping, etc.) are not designed to support data cables. This condition was observed and confirmed by the VP of Facilities and Support Services on 7/17/12.

Examples include but are not limited to:

1) 3rd Floor Center Building - corridor near vending machines

2) 1st Floor Center Building in corridor in front of EVS Closet (near Walgreens)

3) North Tower Wing, 11th Floor - Part of Elevator Lobby leading to OB Unit

4) North Tower Wing, 11th Floor - Post Partum Room 1110

5) North Tower Wing, 8th Floor near Telecommunication Closet

6) North Tower Wing, 4th Floor exit access corridor by Patient Room 4143

7) North Tower Wing Lower Level CPD Storage exit access corridor near the Electrical Closet

B) Based upon random observation on multiple floors and in multiple buildings or wings, the surveyors find that switch gear and electrical panels are not installed and maintained in accordance with NFPA 70:

1) Corrected 04/18/13

2) Switchgear and panels lack panel identification. Electrical panels have spares that are not identified in accordance with NFPA 70. One or more circuits in electrical panels are on and do not identify the circuit in use in accordance with NFPA 70. Based upon the pattern observed, the surveyors expect to find this condition in every electrical panel in the facility. This condition was observed and confirmed by the VP of Facilities and Support Services on 7/17/12. Locations include but are not limited to:

a) 4th Floor West Mechanical Penthouse - Panel D4A and XQ4D

b) Corrected 04/18/13

c) 2nd Floor Center Wing two story Mechanical Room near the fire separation in the corridor between the North Clinic and the Center Wing - Panel R-IE-R2

d) Corrected 04/18/13

e) Corrected 04/18/13

C) Based on random observation the surveyors find that electrical systems and materials are not installed and maintained in accordance with NFPA 70: Examples include:

1) 3rd Floor Center Wing/3 North Clinic - the two story mechanical room (HVAC systems) near the fire separation in the corridor has multiple electrical junction boxes that lack covers.

2) Basement Level Rogers/Center Wing South Mechanical Room - one fluorescent light fixture (in the south end of the Mech Room?) is suspended from a chain that is attached to ductwork above and is not supported in accordance with NFPA 70.

End


16339

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. The deficiencies may lead to a lack of power for critical care areas which could affect patients, staff and visitors during a fire event.

Findings include:

A. 10:15AM, 07/18/2012 North Tower Wing, 4th Floor- Electrical panels were observed at which a clear space of 3'-0" is not being maintained due to a 4 foot ladder that is being stored in front of the panel to comply with NFPA 70 1999 110-26(a)

C. In the afternoon, 07/18/2012 North Tower Wing, 2nd Floor near the OR Supervisor's Room - Electrical panels A2D, A2S and CA2S were observed that are being blocked with a chair and a cart which the required 3'-0" clear space is not being maintained to comply with NFPA 70 1999 110-26(a)

A) Corrected 04/18/13




17659

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1. Corrected 04/18/13

2. The surveyor did not find a single lockable disconnect for each elevator's emergency lighting, receptacle, and ventilation as required by NFPA-70, Section 620-53.

3. The surveyor did not find that the disconnect for the emergency lighting and controls for the elevators were properly labeled in accordance with NFPA-70, Section 620-53.

A) Multiple elevators are not installed and tested in accordance with 19.5.3 and 9.4.3.2 of NFPA 101 and ASME/ANSI A17.3, Safety Code for Existing Elevators.

1) Corrected 04/18/13

2) The Center Stair of the North Clinic has a door in the stair at the Basement Level that is identified as "Mechanical Room OE 59". This door provides access under the stair to a Sump Room and the elevator pit for two of four elevators. The space under the stair does not comply with ASME/ANSI A17.3, NFPA 101 and NFPA 13.

a) The elevator pit is open to the Sump Room. The drywall partition between the Sump Room and the elevator pit has been partially removed in the portion of the Sump Room with low head room. The lack for a two hour fire separation makes the elevator pit part of a space that is not permitted to be under the stair in accordance 7.1.3.2.3 and 7.2.2.5.3

b) The Sump Room has a sprinklered head but lacks sprinkler protection in two low ceiling areas of the room in accordance with NFPA 13.

b) The above elevator pit had debris piled up neatly in one corner of the pit with a broom against the wall.

End