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Based on observations made during the survey of the facility while accompanied by the Dir. Of Plant Ops it was observed that the facility was not in compliance with regards to the required 2 HOUR OCCUPANCY SEPARATION between the Licensed Hospital and an adjacent Non-Licensed Clinic that is in the same building but not part of the Hospital.
Contiguous Non-Health Care Occupancies Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than 2-hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served. 18.1.3.4.1, 19.1.3.4.1

Based on observations made during the survey of the facility while accompanied by the Dir. Of Plant Ops it was observed that the facility was not in compliance with regards to maintaining correct "Record Drawings" of the facility's current plan layout configuration.

REMARKS:
The Surveyor requested to see the facility's Architectural Floor Plan and Life Safety Floor Plan drawings (from the Facility's on-site Record Documents) for the purpose of assisting with the required Survey. The Facility responded to the Surveyor's request. Following the initial response, both the Surveyor and the Director Of Plant Ops observed there was a "mix" of plan drawings reflecting multiple versions of plan configurations. They were drawn at different times in the Hospital's History. However, there were no drawings in the total "mix" of different plan versions which entirely reflected current layout for as-built conditions - including the Architectural background plan layout for the Life Safety Floor Plan.

Each of the various versions of floor plan layouts included some or all of the following 3 conditions within the "mix" of plan versions:
" Condition 1 - Some of the plan information represents current conditions.
" Condition 2 - Some of the plan information represents former conditions.
" Condition 3 - Some of the plan information represents proposed but never built conditions.

The facility shall provide corrected and accurate floor plan layout configurations for the Architectural Floor Plan and Life Safety Floor Plan drawings in accordance with the requirements of the following:
Hospital Licensing Rules, 2007: 133.16 (h)
(h) Retention of drawings, manuals and design data.
(1) As built drawings. Upon occupancy of the building or portion thereof, the owner shall retain as part of the hospital's permanent records, a complete set of legible architectural plans of each building level, fire safety plans as described in subsection (f)(2)(B) of this section for each floor reflecting fire safety requirements, and all single line diagrams described in subsection (f)(2)(F)(v) of this section, drawings for fixed equipment, and mechanical and electrical systems, as installed or built.
(2) Manuals. Upon completion of the contract, the owner shall retain as part of the hospital's permanent records a complete set of manufacturers' operating, maintenance, and preventive maintenance instructions; parts lists; and procurement information with numbers and a description for each piece of equipment. Facility staff shall also be provided with instructions on how to properly operate systems and equipment. Required information shall include energy ratings as needed for future conservation calculations.
(3) Design data. The owner shall retain in the hospital's permanent records complete design data for the facility. This shall include structural design loadings; summary of heat loss assumption and calculations; estimated water consumption; medical gas outlet listing; list of applicable codes; and electric power requirements of installed equipment. All such data shall be supplied to facilitate future alterations, additions, and changes, including, but not limited to, energy audits and retrofit for energy conservation.