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1. Portions of the building were found to have unprotected structural steel. The surveyor finds that portions of structural beams have missing fire proofing. Example locations include:

a) Fourth Floor - Outpatient: Toilet Room in NW Doctor's Office west corridor.

2. Certain areas have spray on fireproofing on the underside of the concrete pan for the waffle slab. During an interview held in the building on the morning of July 14, 2010, the provider ' s Supervisor of Construction was not able to identify the UL Designs used to obtain the necessary construction type throughout the building. " Documentation for the construction assemblies to comply with 19.1.6.2 and NFPA 220 1999 was not available on site (No UL Design Numbers).

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.

Findings include:

A. Corrected 12/28/10.

B. The 4th Floor Outpatient Unit exit access corridor has a nursing station that is open to the corridor. The nurse's station lacks 24 hour supervision. The nursing station is smoke detected but not sprinklered in accordance with the exceptions under 19.3.6.1.

UPDATE 12/28/10: The plan of correction indicated that this nurse station qualified under Exception No. 3 of 19.3.6.1 as a nurse station. However, this exception implies that the nurse station is staffed or otherwise supervised in accordance with the NFPA 101 Handbook commentary which states "Staff supervision is important; it allows staff to see, hear or smell a developing fire or to prevent the ignition of a fire by virtue of their presence." Since this staff supervision is not available on a 24 hour basis, the space does not qualify as a nurse station under Exception No. 3. Since this building has construction type and vertical opening deficiencies, a fire developing on this floor can directly affect patients on other floors. Surveyor notes that Exception No. 6 may be an alternative to separation of the space from the corridor if the space and the corridors onto which the space opens onto located in the same smoke compartment are provided with smoke detection and the space is provided with sprinkler protection.

UPDATE June 1, 2011, Surveyor observed and questioned staff as to the function of this area. The surveyor informed the head of facilitys that in order to meet 19.3.6.1. exception #6, sprinklering of this space is an option to meet the requirements.

C. Corrected 12/28/10.
D. Corrected 12/28/10.

Based on random observation during the survey walk-through, not all ventilation shafts or floor/ceiling assemblies are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. Corrected 06/1/11
B. Corrected 12/28/10.

C. Sixth Floor: The ventilation shaft that connects 4 stories or more by Stair #2 was observed to not carry 2 hour rated enclosure as required by 19.3.1.1.

D. Corrected 12/28/10.
E. Corrected 12/28/10.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. Corrected 12/28/10.

B. Common path of travel was observed to exceed 75 feet as required by 39.2.5.3.
Locations observed include:

1. First Floor, Old Recovery Room corridor leading to the old OR's.

UPDATE 12/28/10: The plan of correction for this deficiency relies upon an FSES. However, it does not appear that the FSES will pass if the construction type (K012), vertical opening (K020) and lack of a building separation (K044)deficiencies that would apply to this building area are not corrected. An explanation of how the parameter values were assigned was not provided with the FSES.

UPDATE 6/1/11: The surveyor was informed that the plan of correction for this deficiency relies upon an FSES. the lack of a building separation (K044) has been corrected. There is a 2-hour separation for the first floor recovery area.

Based on document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

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

1. Not all existing Ventilation shaft are identified on the Life Safety master Plan. Example: Sixth Floor-Ventilation Shafts on the West Side.

UPDATE 12/28/10: This specific deficiency location was not reviewed during this follow-up survey. Surveyor notes that the correction noted for deficiency K067.A.2 indicated that a shaft had been removed by rerouting exhaust ductwork horizontally and slab penetrations sealed with concrete. However, the reference plans indicated that a shaft still existed.

UPDATE 6/1/11: at 1:15pm the Surveyor discussed with the facility representatives items of concern over the updated Life Safety Floor plans. This K-Tag shall remain open until the completion of all other outstanding deficiencies which may cause a change to the means of egress, location of hazardous areas and the fire resistance rating of any vertical opening.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A.

Findings include:

A. The deficiencies listed below were observed at a series of toilet exhaust ducts throughout the 1970 Building. Surveyor 14290 notes that it appears that the cited conditions exist in at least 8 locations on the Sixth through Second Floors. Deficiencies observed include:
1. The toilet exhaust ducts were observed to not be enclosed in shafts which which carry a minimum 2 hour fire resistance rating, as required by NFPA 90A 1999 3-3.4.1., because the enclosures for the ducts consist of drywall or plaster on the outside of metal studs only and because they do not extend from the ceiling to the underside of the deck above.

2. No fire dampers, required by NFPA 90A 1999 3-3.4.4., were observed where the toilet exhaust ducts penetrate the enclosure walls.

UPDATE 6/1/11 The Surveyor was informed by the Head of Facility's that fire dampers are in the process of being installed. The enclosure walls have been sealed and completed. The Surveyor was informed that the Facility has applied for an FSES for the lack of a fire resistance rating for the shaft walls.

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.


UPDATE 6/1/11
This K-Tag shall remain open until the completion of damper work for K-Tag 067 items 1 and 2. Interim Life Safety Measures are to remain in place until the damper installation work is complete. Confirmation of installations and the Interim Life Safety Measures will be required during a subsequent follow-up survey.