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Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to one unsealed cable and one conduit penetration of fire-rated floor in accordance with NFPA 101 19.1.6.2 and 8.2.3.2.4. This deficient practice affected 1 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff D (plant operations director), Staff F (plant operations mechanic) and Staff G (plant operations mechanic) 8/24/2010, Surveyor 12316 observed at 3:02 pm that the 2 hr fire-rated floor in the electrical closet adjacent to X-Ray Rooms 1 and 2 had cable and conduit penetrations that were not fire-stopped with fire-rated sealant to maintain 2-hr fire resistance rating of the floor construction.

The above deficiency was acknowledged by the plant operations director and plant operations mechanic at the time of discovery, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to either lack of required ? hr corridor wall separation of one office space from corridor, or unsealed pipe and cable penetrations in corridor wall above ceiling in accordance with NFPA 101 19.3.6.1. This deficient practice affected 3 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff A (president and chief executive officer), Staff D (plant operations director), Staff E (safety officer), Staff F (plant operations mechanic), and Staff H (plant operations mechanic) 8/23/2010, Surveyor 12316 observed in the following 3 locations that the corridor wall had either unsealed penetrations or did not provide ?-hr fire resistance rating.

1. On 8/23/2010 at 1:45 pm, the sliding glass window of approximately 4 ' x 3 ' -6 " high in the corridor wall of the Cashier ' s Office on the Ground Floor did not provide a ? hr fire resistance rating in accordance with the NFPA 101 19.3.6.2.1 requirement. The windows in the corridor wall were not fixed fire window assemblies in accordance with NFPA 101 8.2.3.2.2, nor was the Cashier ' s office and the adjacent corridor protected with an electrically supervised automatic smoke detection system in accordance with the NFPA 101 19.3.6.1 Exception No. 6(a) to consider the office as a space open to corridor.

2. On 8/23/2010 at 1:55 pm, the annular gap of one pipe penetration above the double doors in corridor wall of the Vending Machine room was not sealed to provide a ? hr fire resistance rating of the wall. The vending machine room is located adjacent to the Electrical Room with automatic transfer switches on the Ground Floor.

3. On 8/23/2010 at 4 pm, one sprinkler pipe and two cable penetrations of corridor wall above ceiling were not sealed to provide a ? hr fire resistance rating of the wall. The corridor wall was located adjacent to the Patient Accounting Office and across the Physical Therapy on the Ground Floor.

The above deficiency was acknowledged by the plant operations director, safety officer and plant operations mechanics at the time of discovery, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to lack of positive latching hardware on corridor doors of the Family Waiting Room in accordance with NFPA 101 18.3.6.1 and 18.3.6.3.2. This deficient practice affected 1 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff D (plant operations director), and Staff G (plant operations mechanic) 8/25/2010, Surveyor 12316 observed at 11:07 am that the Family Waiting Room on the 2nd Floor did not have a positive latching hardware on the glass corridor doors, nor was the space protected with an electrically supervised automatic smoke detection system in accordance with the NFPA 101 18.3.6.1 Exception No. 7(b).

The above deficiency was acknowledged by the plant operations director at the time of discovery, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to fire-rated doors of two hazardous areas held open with a rope, and not maintained to automatically or self-close in accordance with NFPA 101 19.3.2.1, 8.4.1.3. This deficient practice affected 2 of 23 smoke compartments in the facility.

Findings include

Item 1. During a tour of the facility with Staff A (president and CEO), Staff D (plant operations director), Staff E (safety officer), Staff F (plant operations mechanic), and Staff G (plant operations mechanic) 8/23/2010, Surveyor 12316 observed at 2:49 pm that one single leaf, ? hr fire-rated door of the Soiled Linen Room was held open with a rope tied to an object on the wall. This did not allow the door to automatically close when the magnetic hold open device releases the door upon activation of the fire alarm system. The Soiled Linen Room is located in between the Clean Linen Room and the Mechanical Room on the Ground Floor of the 1963 Building.

Item 2. During a tour of the facility with Staff D (plant operations director), Staff F (plant operations mechanic), Staff G (plant operations mechanic), and Staff J (materials management supervisor) on 8/24/2010, Surveyor 12316 observed at 2:20 pm that one leaf of ? hr fire-rated double doors on the west wall of the Central Supply Room on the Ground Floor was held open with a rope tied to an object on the wall. This did not allow the door to self-close and keep the door closed when not in use.

The above deficiency was acknowledged by Staff D (plant operations director) and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to unsealed penetration of one smoke barrier in accordance with the NFPA 101 19.3.7.3 and 8.3 requirements. This deficient practice affected 2 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff D (plant operations director), Staff F (plant operations mechanic) and Staff G (plant operations mechanic) on 8/24/2010, Surveyor 12316 observed at 1:35 pm that one cable penetration with multiple cables through a smoke barrier was not sealed. The lack of fire-stopping sealant around the cable did not provide the required ? hr fire resistance rating of the smoke barrier wall, which was located adjacent to the Stairwell #4 on the 1st Floor.

The above deficiency was acknowledged by the plant operations director and plant operations mechanics at the time of survey, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to the failure of one pair of smoke doors to fully close in accordance with the NFPA 101 19.3.7.6 requirement. This deficient practice affected 2 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff D (plant operations director), Staff E (safety officer), Staff F (plant operations mechanic), and Staff H (plant operations mechanic) on 8/23/2010, Surveyor 12316 observed at 2:23 pm that the double smoke doors across from the Female Locker Room on the Ground Floor did not fully close when tested.

The above deficiency was acknowledged by the plant operations director, safety officer, and plant operations mechanics at the time of survey, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to a set of fire-rated corridor doors of one hazardous area not installed in accordance with NFPA 101 18.3.6.1, 8.4, 8.2.3.2.1. This deficient practice affected 1 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff E (safety officer), Staff G (plant operations mechanic), and Staff H (plant operations mechanic) 8/24/2010, Surveyor 12316 observed at 11:35 am that the gap at the meeting edge of a ? hr fire-rated double doors of the medical records Storage Room on the Ground Floor had more than 1/8 of an inch allowed for fire-rated wood doors in accordance with NFPA 80 (1999) 2-3.1.7.

The above deficiency was acknowledged by Staff D (plant operations director) and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to sprinkler system pipe supporting cables in a circular loop in one hazardous area. This affected 1 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff E (safety officer), Staff F (plant operations mechanic), and Staff J (materials management supervisor) on 8/24/2010, Surveyor 12316 observed at 11:48 am that multiple cables were arranged to form a circular bundle - was attached to and supported by a sprinkler branch line - in the Central Supply Room on the Ground Floor. The sprinkler piping is not designed to take this additional load and is unsafe.

The above deficiency was confirmed with Staff D (plant operations director), Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to (i) lack of isolation smoke dampers to isolate one air-handling unit, and (ii) lack of duct smoke detector in the supply side of the air-handling unit AC#2 in accordance with NFPA 90A 2-3.9.2 and 4-4.2. This affected some areas of the Ground Floor and 1st Floor.

Findings include

Item 1. During a tour of the facility with Staff D (plant operations director), Staff F (plant operations mechanic), and Staff G (plant operations mechanic) on 8/24/2010, Surveyor 12316 observed at 2:55 pm that the air-handling unit AHU#1 of a 21500 cfm (cubic feet per minute) capacity did not have isolation smoke dampers on the supply and return sides. This unit is located in the Mechanical Room on the Ground Floor adjacent to the Medical Record Storage, and serves the Ground Floor and 1st Floor of the 1990 building.

Item 2. Based on interview with Staff D (plant operations director) and Staff G (plant operations mechanic) on 8/25/2010 at 3 pm, it was revealed that the air-handling unit AHU#2 of 4000 cfm capacity did not have a duct smoke detector on the supply side of the unit to shut down the fan upon detection of smoke. This unit is located in the Mechanical Room on the Ground Floor adjacent to the Male Locker Room on the Ground Floor, and serves the 2nd Floor above.

The above deficiency was confirmed with the plant operations director, Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients and staff of the facility due to trash and soiled linen receptacles not stored in a room protected as a hazardous area in accordance with NFPA 101 18.7.5.5. This deficient practice affected 1 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff E (safety officer) on 8/24/2010, Surveyor 12316 observed at 11:05 am that 3 linen and 1 trash receptacles of a combined capacity of more than 32 gal were stored in one location in corridor across nurse station near Elevator #5 in the Emergency Department. The soiled linen and trash containers exceeded the allowable density of 0.5 gal per sq ft, but were not stored in a room protected as a hazardous area in accordance with NFPA 101 18.7.5.5.

The above deficiency was acknowledged by safety officer at the time of survey, and confirmed with Staff D (plant operations director), Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility did not provide medical gas and vacuum system as required by NFPA 99 due to lack of a 2nd master alarm panel. This deficiency affected the entire facility.Findings include
On 8/25/2010 at 11:45 am, Surveyor #12316 along with Staff D (plant operations director) and Staff G (plant operations mechanic) observed that the 2nd location of medical gas and vacuum system master alarm panel was no longer continuously attended by hospital staff in accordance with NFPA 99 (1999) 4-3.1.2.2(b)(2). This location was in an old emergency department suite, which has now been relocated to the new 2010 addition since the middle of August 2010.

The above deficiency was acknowledged by the plant operations director at the time of survey, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and staff interview, the facility failed to provide working space in front of electrical panel and equipment in two locations in accordance with NFPA 70 110-26. This affected 2 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff D (plant operations director), Staff F (plant operations mechanic), and Staff G (plant operations mechanic) on 8/24/2010, Surveyor 12316 observed at 2:37 pm that one cardboard box labeled fax machine was stored in front of one electrical panel in the Mechanical Room with medical gas and vacuum system equipment, and air handling unit. The object did not provide working space required in front of electrical panels and switches in accordance with NFPA 70 110-26. The Mechanical Room is located in the Ground Floor adjacent to the IT department.

On 8/25/2010, Surveyor 12316 along with the plant operations director also observed at 8:47 am that two objects - one trash cart of 2 ' x 4 ' x 2 ' approximate size, and one cardboard box of approximately 2 ' x 2 ' x 2 ' - were stored in front of one equipment branch automatic transfer switch in the mechanical room on the 2nd Floor. This did not provide the required working space in front of electrical equipment.

The above deficiency was acknowledged by the plant operations director at the time of survey, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

NFPA 70 110-26.
"Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment ... "

NFPA 70 110-26(b) Clear Spaces.
"Working space required by this section shall not be used for storage ..."

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to one unsealed cable and one conduit penetration of fire-rated floor in accordance with NFPA 101 19.1.6.2 and 8.2.3.2.4. This deficient practice affected 1 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff D (plant operations director), Staff F (plant operations mechanic) and Staff G (plant operations mechanic) 8/24/2010, Surveyor 12316 observed at 3:02 pm that the 2 hr fire-rated floor in the electrical closet adjacent to X-Ray Rooms 1 and 2 had cable and conduit penetrations that were not fire-stopped with fire-rated sealant to maintain 2-hr fire resistance rating of the floor construction.

The above deficiency was acknowledged by the plant operations director and plant operations mechanic at the time of discovery, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to either lack of required ? hr corridor wall separation of one office space from corridor, or unsealed pipe and cable penetrations in corridor wall above ceiling in accordance with NFPA 101 19.3.6.1. This deficient practice affected 3 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff A (president and chief executive officer), Staff D (plant operations director), Staff E (safety officer), Staff F (plant operations mechanic), and Staff H (plant operations mechanic) 8/23/2010, Surveyor 12316 observed in the following 3 locations that the corridor wall had either unsealed penetrations or did not provide ?-hr fire resistance rating.

1. On 8/23/2010 at 1:45 pm, the sliding glass window of approximately 4 ' x 3 ' -6 " high in the corridor wall of the Cashier ' s Office on the Ground Floor did not provide a ? hr fire resistance rating in accordance with the NFPA 101 19.3.6.2.1 requirement. The windows in the corridor wall were not fixed fire window assemblies in accordance with NFPA 101 8.2.3.2.2, nor was the Cashier ' s office and the adjacent corridor protected with an electrically supervised automatic smoke detection system in accordance with the NFPA 101 19.3.6.1 Exception No. 6(a) to consider the office as a space open to corridor.

2. On 8/23/2010 at 1:55 pm, the annular gap of one pipe penetration above the double doors in corridor wall of the Vending Machine room was not sealed to provide a ? hr fire resistance rating of the wall. The vending machine room is located adjacent to the Electrical Room with automatic transfer switches on the Ground Floor.

3. On 8/23/2010 at 4 pm, one sprinkler pipe and two cable penetrations of corridor wall above ceiling were not sealed to provide a ? hr fire resistance rating of the wall. The corridor wall was located adjacent to the Patient Accounting Office and across the Physical Therapy on the Ground Floor.

The above deficiency was acknowledged by the plant operations director, safety officer and plant operations mechanics at the time of discovery, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to lack of positive latching hardware on corridor doors of the Family Waiting Room in accordance with NFPA 101 18.3.6.1 and 18.3.6.3.2. This deficient practice affected 1 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff D (plant operations director), and Staff G (plant operations mechanic) 8/25/2010, Surveyor 12316 observed at 11:07 am that the Family Waiting Room on the 2nd Floor did not have a positive latching hardware on the glass corridor doors, nor was the space protected with an electrically supervised automatic smoke detection system in accordance with the NFPA 101 18.3.6.1 Exception No. 7(b).

The above deficiency was acknowledged by the plant operations director at the time of discovery, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to fire-rated doors of two hazardous areas held open with a rope, and not maintained to automatically or self-close in accordance with NFPA 101 19.3.2.1, 8.4.1.3. This deficient practice affected 2 of 23 smoke compartments in the facility.

Findings include

Item 1. During a tour of the facility with Staff A (president and CEO), Staff D (plant operations director), Staff E (safety officer), Staff F (plant operations mechanic), and Staff G (plant operations mechanic) 8/23/2010, Surveyor 12316 observed at 2:49 pm that one single leaf, ? hr fire-rated door of the Soiled Linen Room was held open with a rope tied to an object on the wall. This did not allow the door to automatically close when the magnetic hold open device releases the door upon activation of the fire alarm system. The Soiled Linen Room is located in between the Clean Linen Room and the Mechanical Room on the Ground Floor of the 1963 Building.

Item 2. During a tour of the facility with Staff D (plant operations director), Staff F (plant operations mechanic), Staff G (plant operations mechanic), and Staff J (materials management supervisor) on 8/24/2010, Surveyor 12316 observed at 2:20 pm that one leaf of ? hr fire-rated double doors on the west wall of the Central Supply Room on the Ground Floor was held open with a rope tied to an object on the wall. This did not allow the door to self-close and keep the door closed when not in use.

The above deficiency was acknowledged by Staff D (plant operations director) and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to unsealed penetration of one smoke barrier in accordance with the NFPA 101 19.3.7.3 and 8.3 requirements. This deficient practice affected 2 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff D (plant operations director), Staff F (plant operations mechanic) and Staff G (plant operations mechanic) on 8/24/2010, Surveyor 12316 observed at 1:35 pm that one cable penetration with multiple cables through a smoke barrier was not sealed. The lack of fire-stopping sealant around the cable did not provide the required ? hr fire resistance rating of the smoke barrier wall, which was located adjacent to the Stairwell #4 on the 1st Floor.

The above deficiency was acknowledged by the plant operations director and plant operations mechanics at the time of survey, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to the failure of one pair of smoke doors to fully close in accordance with the NFPA 101 19.3.7.6 requirement. This deficient practice affected 2 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff D (plant operations director), Staff E (safety officer), Staff F (plant operations mechanic), and Staff H (plant operations mechanic) on 8/23/2010, Surveyor 12316 observed at 2:23 pm that the double smoke doors across from the Female Locker Room on the Ground Floor did not fully close when tested.

The above deficiency was acknowledged by the plant operations director, safety officer, and plant operations mechanics at the time of survey, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to a set of fire-rated corridor doors of one hazardous area not installed in accordance with NFPA 101 18.3.6.1, 8.4, 8.2.3.2.1. This deficient practice affected 1 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff E (safety officer), Staff G (plant operations mechanic), and Staff H (plant operations mechanic) 8/24/2010, Surveyor 12316 observed at 11:35 am that the gap at the meeting edge of a ? hr fire-rated double doors of the medical records Storage Room on the Ground Floor had more than 1/8 of an inch allowed for fire-rated wood doors in accordance with NFPA 80 (1999) 2-3.1.7.

The above deficiency was acknowledged by Staff D (plant operations director) and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to sprinkler system pipe supporting cables in a circular loop in one hazardous area. This affected 1 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff E (safety officer), Staff F (plant operations mechanic), and Staff J (materials management supervisor) on 8/24/2010, Surveyor 12316 observed at 11:48 am that multiple cables were arranged to form a circular bundle - was attached to and supported by a sprinkler branch line - in the Central Supply Room on the Ground Floor. The sprinkler piping is not designed to take this additional load and is unsafe.

The above deficiency was confirmed with Staff D (plant operations director), Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to (i) lack of isolation smoke dampers to isolate one air-handling unit, and (ii) lack of duct smoke detector in the supply side of the air-handling unit AC#2 in accordance with NFPA 90A 2-3.9.2 and 4-4.2. This affected some areas of the Ground Floor and 1st Floor.

Findings include

Item 1. During a tour of the facility with Staff D (plant operations director), Staff F (plant operations mechanic), and Staff G (plant operations mechanic) on 8/24/2010, Surveyor 12316 observed at 2:55 pm that the air-handling unit AHU#1 of a 21500 cfm (cubic feet per minute) capacity did not have isolation smoke dampers on the supply and return sides. This unit is located in the Mechanical Room on the Ground Floor adjacent to the Medical Record Storage, and serves the Ground Floor and 1st Floor of the 1990 building.

Item 2. Based on interview with Staff D (plant operations director) and Staff G (plant operations mechanic) on 8/25/2010 at 3 pm, it was revealed that the air-handling unit AHU#2 of 4000 cfm capacity did not have a duct smoke detector on the supply side of the unit to shut down the fan upon detection of smoke. This unit is located in the Mechanical Room on the Ground Floor adjacent to the Male Locker Room on the Ground Floor, and serves the 2nd Floor above.

The above deficiency was confirmed with the plant operations director, Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients and staff of the facility due to trash and soiled linen receptacles not stored in a room protected as a hazardous area in accordance with NFPA 101 18.7.5.5. This deficient practice affected 1 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff E (safety officer) on 8/24/2010, Surveyor 12316 observed at 11:05 am that 3 linen and 1 trash receptacles of a combined capacity of more than 32 gal were stored in one location in corridor across nurse station near Elevator #5 in the Emergency Department. The soiled linen and trash containers exceeded the allowable density of 0.5 gal per sq ft, but were not stored in a room protected as a hazardous area in accordance with NFPA 101 18.7.5.5.

The above deficiency was acknowledged by safety officer at the time of survey, and confirmed with Staff D (plant operations director), Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and interview, the facility did not provide medical gas and vacuum system as required by NFPA 99 due to lack of a 2nd master alarm panel. This deficiency affected the entire facility.Findings include
On 8/25/2010 at 11:45 am, Surveyor #12316 along with Staff D (plant operations director) and Staff G (plant operations mechanic) observed that the 2nd location of medical gas and vacuum system master alarm panel was no longer continuously attended by hospital staff in accordance with NFPA 99 (1999) 4-3.1.2.2(b)(2). This location was in an old emergency department suite, which has now been relocated to the new 2010 addition since the middle of August 2010.

The above deficiency was acknowledged by the plant operations director at the time of survey, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

Based on observation and staff interview, the facility failed to provide working space in front of electrical panel and equipment in two locations in accordance with NFPA 70 110-26. This affected 2 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff D (plant operations director), Staff F (plant operations mechanic), and Staff G (plant operations mechanic) on 8/24/2010, Surveyor 12316 observed at 2:37 pm that one cardboard box labeled fax machine was stored in front of one electrical panel in the Mechanical Room with medical gas and vacuum system equipment, and air handling unit. The object did not provide working space required in front of electrical panels and switches in accordance with NFPA 70 110-26. The Mechanical Room is located in the Ground Floor adjacent to the IT department.

On 8/25/2010, Surveyor 12316 along with the plant operations director also observed at 8:47 am that two objects - one trash cart of 2 ' x 4 ' x 2 ' approximate size, and one cardboard box of approximately 2 ' x 2 ' x 2 ' - were stored in front of one equipment branch automatic transfer switch in the mechanical room on the 2nd Floor. This did not provide the required working space in front of electrical equipment.

The above deficiency was acknowledged by the plant operations director at the time of survey, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

NFPA 70 110-26.
"Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment ... "

NFPA 70 110-26(b) Clear Spaces.
"Working space required by this section shall not be used for storage ..."