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A. Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. A steel beam was observed, immediately south of the North Entry Vestibule, that is not fireproofed in a manner consistent with the designated building construction type; refer to NFPA 220 1999 3-1.

09/10/10: The above item was corrected; however, a steel beam above the ceiling in the north, outside wall, in the same vestibule (next to Administration) was exposed and unprotected as a fire rated assembly.

A. (Modified 09/08/10): Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Areas open to corridors, were observed to lack smoke detectors and sprinkler coverage on accordance with Exception 6. [subpart(b)] to 19.3.6.1. Locations observed include:
1. Corrected 09/08/10
2. Administrative Assistant's Office (walls of room do not extend to the underside of the deck above in a northwest lobby. 09/08/10 - the office area has been removed from the Lobby. It remains as a waiting area open to a corridor and it lacks smoke detection (spaced in accordance with NFPA 72) or visual supervision, in accordance with Exception 6. [subpart(b)] to 19.3.6.1.




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B) By direct observation the surveyor finds:

In the west smoke compartment the interstitial space between the ceiling of the corridors and the roof deck is being used as a common plenum for ventilation exhaust air for the entire compartment. Transfer of exhaust air from rooms off the corridor is by way of transfer grills installed in the corridor walls as prohibited by NFPA 101, 19.3.6.4.

09/08/10 - The above item was not corrected in accordance with the last submitted PoC. The sprinkler system that is being installed as part of the PoC is currently incomplete.

Also, as part of the above sprinklered project, multiple ceiling tiles in the corridors were displaced. The corridor ceilings are not being maintained in a smoke tight condition in accordance with the PoC.

Adequate interim life safety measures were not found for the above conditions.

A) (New 09/08/10) - Moved from K029: Multiple fire doors, doors to hazardous areas, etc, have magnetic hold open devices but lack local smoke detectors on one of both sides of the door (as determined by NFPA 72), in accordance with 7.2.1.8 (NFPA 101 - 2000). Locations include:

South Medical Records Room

Center Medical Records Room (the corridor door to this room also hangs up on the carpet).

North Medicare Records Room

Corridor door(s) to Purchasing Storage Room

A) (New 09/08/10) Existing designated smoke barriers have been penetrated and not repaired by the ongoing sprinkler project. Example: large hole in the smoke barrier, above the ceiling, in the wall between the ED and the new Main Entrance.

A) (New 09/08/10): In the west smoke compartment the interstitial space between the ceiling of the corridors and the roof deck is used as a common plenum for ventilation exhaust air for the entire compartment. Transfer of exhaust air from rooms that are designated hazardous areas, into the corridor ceiling plenum is done via transfer grills installed in the corridor walls of the hazardous area and/or in the former bathrooms of such hazardous areas.

This arrangement allows for the movement of smoke out of the hazardous areas into other areas. The transfer grills in such hazardous areas lacks smoke dampers in in duct smoke detection in accordance with NFPA 90A, NFPA 101 (8.4 and 19.3.2.1).

Locations include but are not limited to soiled utility rooms, supply rooms, medical records rooms, etc.




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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.

Findings include:

A. Pipe or other penetrations through enclosure walls of hazardous areas not covered by a sprinkler system were observed that are not sealed against the passage of fire as required by 19.3.2.1. and 8.2.3.2.4.2. Locations observed include:

1. X-Ray File Room. - not corrected 09/08/10
2. Corrected 09/08/10.

3. Corrected 09/08/10

B. Hazardous areas not covered by a sprinkler system were observed at which doors do not carry a minimum fire resistance rating of 3/4 hour as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

1. Corrected 09/08/10
2. Deleted 09/08/10 - see K021 and K029
under 07113

3. Deleted 09/08/10 - see K021 and K029
under 07113

4. Deleted 09/08/10.
5. Deleted 09/08/10 - could not find room

C. Corrected 09/08/10

D. Deleted 09/08/10 - see K021

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. Corrected 09/08/10

B. Corrected 09/08/10

C. During a test of the building fire alarm system conducted on the afternoon of January 20, 2010, the smoke detector located near the exit door from the Glass Corridor/Cafeteria Building (immediately south of the Hospital) was observed to not activate the Hospital fire alarm annunciation system as required by 9.6.2.1(2).

A. Based on random observation 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 in accordance with 19.2.3.3. Carts and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. Corrected 09/08/10

2. Corrected 09/08/10

3. (New 09/08/10) Gurneys in exit access
corridor outside of surgical area

4. (New 09/08/10): The new CT Area is
not identified as a suite on any plans.
The portable X-ray machine left in the
corridor of this area does not comply
with 19.3.6.1.

Also, the corridor in this area appears to
be a required exit path from the north
end of the Emergency Department (and a
corridor may not exit through a suite).

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. 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. Interim life safety measures were reviewed on site and were found to be inadequate relative to the ongoing sprinkler project. This project has created additional life safety code deficiencies.

B. Materials were observed being stored less than 18" below sprinkler heads as prohibited by NFPA 13 1999 5-6.6. (for standard pendant and upright spray sprinkler heads) and 5-7.6. (for standard sidewall sprinkler heads). Locations observed include:

1. Purchasing Storage Room. - not corrected 09/08/10

2. Corrected 09/08/10

C. (New 09/08/10): Side wall sprinkler heads have been installed in many locations. 18" of unobstructed space is not maintained below this sidewall heads and/or the sprinkler heads are not installed in accordance with NFPA 13: Locations include:

1. North Medical Records Room

2. Center Medical Records Room

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.

Findings include:

A. Corrected 09/08/10

B. (New 09/08/10) 36" of clear space in front of disconnects, electrical panels and the emergency stop for the generator was not maintained in the Boiler Room, in accordance with NFPA 70.

A) (New 09/08/10) Existing designated smoke barriers have been penetrated and not repaired by the ongoing sprinkler project. Example: large hole in the smoke barrier, above the ceiling, in the wall between the ED and the new Main Entrance.