HospitalInspections.org

A. Based upon random observation, document review (and the lack of documentation) and based upon interview of the Director of Facilities on May 21, 2013 and May 22, 2013, the surveyor finds that the East Building, the Center Building and the West Building are constructed with reinforced concrete structural systems. However, the provider lacks historical data, U L Design Numbers, and or other information which identifies the Construction Type of each Building as defined by NFPA 220. The provider is not able to demonstrate that each of the three buildings is at least Type II (222) construction, if not Type I (332) construction in accordance with 19.1.6.2.

B. Basement Level Center Building: The Bed Storage/Furniture Storage Room is ribbed slab concrete construction above with a monolithic plaster ceiling installed on the bottom of the concrete. This plaster ceiling has large voids in it. The provider lacks documentation that demonstrates how the floor assembly it at least two hour rated without the plaster ceiling.

A. Based upon random observation, document review (and the lack of documentation) and based upon interview of the Director of Facilities on May 21, 2013 and May 22, 2013, the surveyor finds that the East Building, the Center Building and the West Building are constructed with reinforced concrete structural systems. However, the provider lacks historical data, U L Design Numbers, and/or other information which identifies the Construction Type of each Building as defined by NFPA 220. The provider is not able to demonstrate that each of the three buildings is at least Type II (222) construction, if not Type I (332) construction in accordance with 19.1.6.2.

A. Based on random observation during fire alarm testing, with the the Senior Director of Facilities Management, on May 23, 2013, the surveyors find that some corridor doors are not installed and maintained in accordance with Chapter 7 and 19.7.2 of NFPA 101.

Findings include:

1. 3rd Floor West Building: The pair of smoke doors/suite doors to the ICU failed to close to latch upon activation of the fire alarm sytem, in accordance with 19.3.7.2 and 7.2.1.8.

a. The West Building Obstetrics/C-Section Unit has a pair of doors where and the automatic opening/hold open functions are these doors are not disabled when the fire alarm system is activated and the doors to not close to latch upon activation of the fire alarm system.



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Based on observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied. This was confirmed by the VP of Ancillary Services and Director of Facilities Management.

B. On the morining of May 21, 2013, the following doors to the exit access corridor did not latch.

1. 3rd floor soiled utility room

2. 3rd floor ICU doors to the corridor

Based on random observation during the survey walk-through, with the the Director of Facilities Management, on May 21, 2013, the surveyors find that some corridor doors are not installed and maintained in accordance with Chapter 7 and 19.7.2 of NFPA 101.

Multiple corridor doors and doors within suites are wedged open. The provider is not able to identify why many of these doors have self closing devices. This condition will allow smoke to spread to the corridor and delays staff response during fire drills and a fire emergency.

Findings include but are not limited to

1. East Building - Doors in most 3rd Floor corridors and suites, including but not limited to Suite 300 and 302.

2. East Building - Doors in 2nd corridors and suites, including but not limited to Suite 200.

Based on random observation during the survey walk-through, with the the Senior Director of Facilities Management, on May 22, 2013, and based on observation of fire alarm testing on May 23, 2013, the surveyors find that some corridor doors are not installed and maintained in accordance with Chapter 7 and 19.7.2 of NFPA 101.

Findings include:

1. TV Room 0418B has a corridor door with a louver in the door that is not permitted under 19.3.6.4.

2. 2nd Floor Center Building:

a. The Surgical Unit is identified as a suite. The pair of auto-open doors at the west end of the suite lack any kind of positive latching hardware and the automatic opening/hold open functions are these doors are not disabled when the fire alarm system is activated.

b. The Staff Break Room has a door that is located at the suite boundary. The door has positive latching hardware; however, the door is routinely propped open.

3. 1st Floor Center Building: The following areas have aluminum and glass corridor doors that do not have positive latching hardware in compliance with 19.3.6.3.2.

a. Corridor door to the Outpatient Pharmacy Waiting Area

b. Corridor door to Admitting/receiving area

c. Lab

4. Multiple 1st Floor corridor doors were wedged open in both corridors and within suite and do not comply with 19.3.6.3.3.

a. Multiple doors inside Admitting/receiving.

b. Multiple corridor doors for OPWC

5. Basement Level corridor doors lack functioning positive latching hardware in accordance with 19.3.6.3.2:

a. Both Women's Locker Rooms

b. Mens Locker Room

5.

B. Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 22, 2013, the surveyors find that vertical openings are not protected and fire barriers are not installed and maintained in accordance with 8.2.5.6, 19.3.1.1 of NFPA 101 - 2000. These condition could allow fire and smoke to spread floor to floor and beyond designated fire barriers during a fire emergency.

Findings include:

1. 5th Floor four hour vestibule between the Center Building and the North Building: A construction project has resulted in the installation of new 4" conduits through the fire rated floor assembly and and through both fire barriers of the vestibule, with large holes and voids around the conduit. The penetrations were not sealed, either temporarily or permanently with fire rated materials in accordance with a U L Design (or equivalent).

The provider also failed to implement adequate interim life safety measures for this condition which would include observation, detection and abatement of the above condition.

2. 3rd Floor Center Building Surgical Suite - The Sterilizer Room next to O R # 7 has two sleeves through the fire rated floor into the space below that are not sealed for two hour fire rated construction.

3. 3rd Floor Center Building Surgical Suite - The Sterilizer Room next to O R # 7 has two duct penetrations into the the fire rated floor without fire dampers installed in accordance with NFPA 90A.

4. 3rd Floor Center Building Surgical Suite - The closet next to O R # 2 has two sleeves through the fire rated floor into the space below that are not sealed for two hour fire rated construction.

5. Basement Level Center Building: The elevator shaft for elevators # 1 and # 2 are open, at the elevator pit at the Basement Level, to an adjacent shaft to the west. The adjacent shaft enclosure has an access door in the elevator lobby at the basement Level that is not fire rated and self closing.






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Based on random observation during the survey walk through while accompanied by engineering staff, not all vertical openings are protected to comply with 19.3.1 and 8.2.5.2. This could contribute to the lack of containment during a fire event. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass between building stories.

A. On the afternoon of May 21, 2013, the provide was installing an additional elevator and an adjacent utiltiy chase. The opening to this vertical shaft was sealed with 1 layer of drywall and metal hat channels. No interim measures were in place. This was confirmed witht eh VP of Ancillary Services and Director of Facilities Management

Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 22, 2013, the surveyors find that fire doors and/or doors that are required to be self closing are held open by means that do not comply with 7.2.1.8 of NFPA 101 - 2000. These conditions could allow fire and smoke to spread during a fire emergency.

Findings include:

1. 3rd Floor Center Building Surgical Suite: There is a pair of designated smoke doors with hold open devices in this suite. The door hold open devices do not release automatically from activation of the fire alarm system. (confirm local smoke detection also)

2. Basement Level Center Building - The Housekeeping Storage Room near Stair # 4 has a corridor door with a magnetic hold open device. A smoke detector is not installed on both sides of this door.

3. Basement Level Center Building - The Linen Room has a a pair of corridor doors with magnetic hold open devices. A smoke detector is not installed on both sides of these doors in accordance with NFPA 72.

Based on renadom observation, exit signs are not located to identify the path of exit. This could affect all residents, staff and visitors who may need to evacuate the building in a timely manner if they are not able to readily identify the pathe of exit.

A. On the afternoon of May 21, 2013, the secondary exit from the Womens Psychatric Unit was not identified by an exit sign. This was confirmed with the VP of Ancillary Services and Director of Facilities Management.

Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 22, 2013, the surveyors find that required smoke barriers are not installed and maintained in accordance with 19.3.7.3 of NFPA 101 - 2000. These condition could allow fire and smoke to spread beyond designated fire/smoke barriers during a fire emergency.

Findings include:

1. (4 - Center Building) The designated one hour smoke barrier roughly in the middle of the 4th Floor of the Center Building has a cable penetration above the ceiling which was not sealed for fire rated construction.

2. (4 - Center Building) The designated one hour smoke barrier roughly in the middle of the 4th Floor of the Center Building has a void in the smoke barrier, as viewed above the ceiling from the Kitchenette, looking to the southwest.

3. (2 - Center Building) The 2nd Floor designated one hour smoke barrier near the elevator and above a pair of opposite swinging doors has a duct penetration above the ceiling that is not sealed as a smoke tight penetration through the smoke barrier.

4. (Bsmt - Center Building) The designated one hour smoke barrier at the Basement Level of the Center Building has a penetration above the ceiling, above a pair of smoke doors, which was not sealed for fire rated construction. The drywall barrier above the ceiling has joints that are not sealed/taped in accordance with a U L Design Number for a one hour barrier.

Based on random observation during the survey walk-through, with the the Senior Director of Facilities Management, on May 22, 2013, the surveyor finds that some hazardous areas are not enclosed in accordance with 19.3.2.1 and 8.4.1 of NFPA 101.

Findings include:

1. 4 - Center: Strategic National Stoke Pile Room 415 has a corridor door that lacks self closing hardware.

2. 3rd Floor Center Building Surgical Suite: This floor is not fully sprinklered (information only)

a. A storage room with a south door to the
aisle inside the suite lacks positive
latching hardware (the latchset has been
removed).

b. Storage Room E3303 is a hazardous
area with a door to a dialysis room. This
door is not fire rated, the glazing in the
door is not fire rated and the door is not
self closing.

c. The former Anesthesia Office, now
storage room, has a door which lacks a
3/4 hour fire rating and self closing
hardware.

d. Operating Room 5 and 6 have been
converted to storage rooms. The
doors to these rooms are not 3/4
hour fire rated doors. The door to
O R # 5 also hangs up on the floor
and does not close to latch. The
door to O R # 6 has a built in
manual hold open device which
does not comply with 7.2.1.8.

e. Sterile Instrument Storage Room
E3317 and Room E3326 - the
doors to these rooms do not
close to latch.

3. The 2nd Floor Back (north) Elevator Foyer has two closets in the west side of the space that are full of combustibles. The rooms lack one hour fire rated enclosure and the doors are not 3/4 hour fire rated doors with self closing hardware.

4. The 2nd Floor Pharmacy Storage Room has a latchset that has been disabled.

5. The provider is not able to demonstrate how the 2nd Floor Pharmacy is not a hazardous area and how is it separated from the Elevator Foyer to the South with a one hour fire barrier.

6. The 2nd Floor Imaging Department has an old Dark Room that is full of combustibles and debris. The door to this room is not a 3/4 hour fire rated door with positive latching hardware.

7. The Basement Level Morgue Elevator Machine Room has a louvered door. The louver is not permitted under 19.3.2.1 and 19.3.6.4.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with NFPA 101-2000, 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

1. On the afternoon of May 21, 2013, Room 246 (across from the psychiatric unit) was found to contain file storage in quantity that would be considered hazardous. The room was sprinklered, but the door was not self closing. This was confirmed with the VP of Ancillary Services and Director of Facilities Management.

Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 21, 2013, the surveyors find that required exit stairs are not installed and maintained in accordance with Chapter 7 and 19.2 of NFPA 101 - 2000. This condition reduces the exit capacity of this stair in an emergency and could result in loss of the exit in a fire emergency.

Findings include:

1. Stair # 3 (East Exit Stair), at the 3rd Floor, has a large wall mounted metal electrical box that extends the length of the east wall of this stair.

a. The box is part of the electrical wiring for a sign mounted on the exterior wall of the stair and is not permitted under 7.1.3.2.1. e) and and 7.2.2.5.3 of NFPA 101.

b. The metal box projects 8" or more into the required exit width of the stair at the 3rd Floor landing and fhe first five to six steps.

2. East Building Stair # 8 has duct penetrations (large duct) through to walls of the stair enclosure, at the 1st Floor above a soffit in the stair. The provider lacks detailed information and photographs that demonstrate how the soffit was constructed as a two hour fire barrier and there are no access panels in the walls above the soffit (note - access panels are not permitted within the stair.

a. The surveyor observed that one duct penetration is installed with a fire damper, however there is a hole or void in the wall around the fire damper.

b. The 2nd duct penetration has no fire damper.

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management , on May 22, 2013, the surveyors find that exit stair enclosures are not installed and maintained in accordance with Chapter 7 and Chapter 8 of NFPA 101 - 2000. Failure to maintain fire separations for exit stairs could result in loss of use in a fire emergency.

Findings include:

1. 1st Floor North Building - Boiler Plant Building and old Laundry Room portion of North Building:

a. Exit Stair # 11 has a stair door with U L Labels that cannot be read. A fire rated B Label door was not found.

b. Exit Stair # 12 is a two story stair. The 1st Floor door to the stair has hardware that can be disabled so that the door does not latch. The door is typically not latched and the specific hardware identified is not permitted on a fire door.

c. Exit Stair # 12 is a two story stair. The stair is supported by unprotected steel legs and angles that are located in an open niche off of a 1st Floor corridor. The support of this stair is not protected as a one hour fire rated assembly and the niche is used for storage.

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management , on May 22, 2013, the surveyors find that exit stair enclosures are not installed and maintained in accordance with Chapter 7 and Chapter 8 of NFPA 101 - 2000. Failure to maintain fire separations for exit stairs could result in loss of use in a fire emergency.

Findings include:

1. The 1st Floor stair door to Exit Stair # 10 has a U L Label that cannot be read. A fire rated B Label door was not found.


2. The Basement stair door to Exit Stair # 10 does not close to latch.

Based on observation during the survey walk-through, not all exit stairs are constructed in accordance with the requirements of 19.2.2.3 & 7.2.2. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by impeding the use of the stairs during building exiting.

A. On the morning of May 21, 2013, the exit star guard rail spacing was larger than the permitted per Section 7.2.2.4.6.

1. Stair #4

2. Stair #5

3. Stair #6

4. Based on the non-compliance of the
guardrail spacing in 3 out of 3 stairs
within the West Building, the remaining
guard rail spacing in all exit stairs
within the facility must be verified. This
was confirmed with the VP of Ancillary
Services and Director of Facilities
Management.

A. Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 21, 2013, the surveyors find that exit stairs and exit paths are not installed and maintained in accordance with Chapter 7 of NFPA 101 - 2000. Exits are not readily available at all times. This condition result in a delay or confusion during the exit process in a fire emergency.

Findings include

1. Exit stairs which continue beyond the level of exit discharge were observed that are not equipped with interrupter gates required by 7.7.3. Locations observed include: Stair # 8 continues to the Basement Level, past the level of exit discharge without a complying interruption.

2. East Building 1st Floor: The east exit door to the outside (with an exit sign) is locked with a magnetic locking device that does not comply with 7.2.1.6.1 or 7.2.1.6.2 and 19.2.2.2.4. The location does not qualify for the use of Exception # 1 under 19.2.2.2.4

B. The 1st Floor has two pairs of existing fire doors marked as an exit path between the East Building to the Center Building. There are no signs on the doors which identify which door must be pulled open in order to exit through the pair of doors to the east.

Based on random observation during the survey walk-through, with the the Senior Director of Facilities Management, on May 22, 2013, the surveyor finds that some exit accesses are not arranged so that exit paths are readily accessible at all times in accordance with 19.2.1.

Findings include:

1. 1st Floor Outpatient Pharmacy. The corridor door to this pharmacy is partially obstructed by a metal locked inside the Pharmacy.

Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with Sections 19.2.1 and 7.2.1.6.1.. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

A. On the morning of May 22, 2013, the OB unity was found to have magnetic locking devices on exits doors that did not release within a certain time frame when pressure was applied to the door. The doors required special knowledge (keypad code) to open the door or a remote release switch at the nurse station. The occupants of the mother/baby unit do not have any clinical need to prevent their egress. This was confirmed with the VP of Ancillary Services and Director of Facilities Management.

Based on observation during fire alarm testing, with the Director of Facilities Management, on the morning of May 23, 2013, the surveyors find that fire barriers are not installed and maintained in accordance with Chapter 7.2.4 of NFPA 101 - 2000. These condition could allow fire and smoke to spread beyond designated fire barriers during a fire emergency.

Findings include

1. West Building 3rd Floor, one door of two pairs of fire doors near Room 337 failed to latch.


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Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, because failure to construct and maintain fire resistive assemblies could allow fire and smoke to pass from one compartment into adjacent fire/smoke compartments.

A. The door coordinators did not function properly and doors would not close to latch.

1. On the morning of May 21, 2013, both cross corridor doors located in the "Chicago vestibule" near the elevator lobby on the 3rd floor did not latch to close. This was confirmed with the VP of Ancillary Services and Director of Facilities Management.

2. On the morning of May 21, 2013, one of the cross corridor doors located in the "Chicago vestibule" near the elevator lobby on the 2nd floor did not latch to close. This was confirmed with the VP of Ancillary Services and Director of Facilities Management.

3. On the afternoon of May 21, 2013, the pair of cross corridor doors to the chemical dependance unit on the 2nd floor was not equipped with a coordinator. This was confirmed with the VP of Ancillary Services and Director of Facilities Management.

Based on observation during the survey walk-through, with the Director of Facilities Management, on May 22, 2013, the surveyors find that fire barriers are not installed and maintained in accordance with Chapter 7.2.4 of NFPA 101 - 2000. These condition could allow fire and smoke to spread beyond designated fire barriers during a fire emergency.

Findings include:

1. The 1st Floor four hour vestibule between the East Building and the Center Building has a cable penetration above the fire doors, above the ceiling, that is not sealed for fire rate construction.

A. The provider furnished Life Safety Plans as information to be used for the survey. The small scale plans dated 2007 were used for 90% of the survey. There is no indication that these small scale plans match completely a large set of plans dated 2010. Based on direct observation and document review the surveyors find the plans provided are not accurate for portions of the building.

Findings include;

1. 3rd Floor Center Building - the west end of the building is not shown accurately. The back elevator foyer (north foyer is used as as storage or holding area and is not identified on plans as a hazardous area with a one hour enclosure.

2. The 2nd Floor new CT Scan Room and nearby areas have not been updated on the Life Safety Plans.

3. The 1st Floor plans show a walk through from the Main Waiting Area into the elevator foyer north of elevators # 1 and # 2. The walk through opening does not exist.

4. The plans dated 2010 use a large dashed red line to identify four hour barriers in the plan key. However, the plans use a smaller dashed red line that does not match the plan key and the designations are not clearly identified.

Based on document review of fire drills records for the previous five months and a random review of records for the previous twelve months and based upon interview of administrative and facilities personnel, including Director of Facilities Management, on May 23, 2013, the surveyors find that fire drills are not always conducted at varying times and varying conditions in accordance with 19.7.1.2.

The surveyors note that the fire alarm system for each of the four buildings are independent of the other building and that fire drills are documented on in the building of activation.

Findings include:

A. Based on document review and random observation, the surveyors note that the fire drill report form does not include that the fire alarm system was audible in the area observed and that the chime code was audible and could clearly be observed. The surveyors note that audible announcements from the switchboard are documented on the fire drill report forms (announcing the fire location with a code red and location) . Based upon testing of the fire alarm system on May 23, 2013, the surveyors observed that the fire alarm chime code is not loud enough to be heard in some areas. This is not being detected during fire drills and/or from testing of the fire alarm system (see also K051.

B. Based upon document review the surveyor finds that a minimal number of fire drills are conducted for each shift for each quarter. Only a portion of each health care floor is observed for each shift each quarter. Example: A fire drill was conducted in one of three smoke compartments of teh West Building at 3:09 pm on March of 2013. The same smoke compartment on the same floor was observed and documented by an observer and the nurse in charge on the unit. The two other health care smoke compartments on the same floor and the six other smoke compartments were not observed or documented.

Out of nine of nine health care occupied smoke compartments in this building, only one of nine receives an observed fire drill, each shift in a three month period.

C. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2.

a. For the 11 pm to 7 am shift, fire drills are typically conducted separately in three of three health care building (include this West Building) between 4:00 am and 5:30 AM.

b. Whether the drill is being conduct for the 1st shift or the 2nd shift, the surveyor notes that fire drills are typically conducted, separately in three of three health care building (include this West Building), around 3:00 pm. The surveyor found other drills ar varying times for the 1st shift (7 am to 3 pm) but found no variation in time for the 2nd shift (3 pm to 11 pm).(3:00 pm only)

Based on document review of fire drills records for the previous five months and a random review of records for the previous twelve months and based upon interview of administrative and facilities personnel, including Director of Facilities Management, on May 23, 2013, the surveyors find that fire drills are not always conducted at varying times and varying conditions in accordance with 19.7.1.2.

The surveyors note that the fire alarm system for each of the four buildings are independent of the other building and that fire drills are documented on in the building of activation.

Findings include:

A. Based on document review and random observation, the surveyors note that the fire drill report form does not include that the fire alarm system was audible in the area observed and that the chime code was audible and could clearly be observed. The surveyors note that audible announcements from the switchboard are documented on the fire drill report forms (announcing the fire location with a code red and location) . Based upon testing of the fire alarm system on May 23, 2013, the surveyors observed that the fire alarm chime code is not loud enough to be heard in some areas. This is not being detected during fire drills and/or from testing of the fire alarm system (see also K051).

B. Based upon document review the surveyor finds that a minimal number of fire drills are conducted for each shift for each quarter. Only a portion of each health care floor is observed. A fire drill is typically conducted in one of two smoke compartments on the same floor. The other health care smoke compartment on the same floor and the six other smoke compartments on three other floors were not observed or documented.

C. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2.

a. For the 11 pm to 7 am shift, fire drills are typically conducted separately in three of three health care building (include this Center Building) between 4:00 am and 5:30 AM.

b. Whether the drill is being conduct for the 1st shift or the 2nd shift, the surveyor notes that fire drills are typically conducted, separately in three of three health care building (include this Center Building), around 3:00 pm. The surveyor found other drills ar varying times for the 1st shift (7 am to 3 pm) but found no variation in time for the 2nd shift (3 pm to 11 pm) (3:00 pm only).

Based on document review of fire drills records for the previous five months and a random review of records for the previous twelve months and based upon interview of administrative and facilities personnel, including Director of Facilities Management, on May 23, 2013, the surveyors find that fire drills are not always conducted at varying times and varying conditions in accordance with 19.7.1.2.

The surveyors note that the fire alarm system for each of the four buildings is independent of the other building and that fire drills are documented only in the building of activation.

Findings include:

A. Based on document review and random observation, the surveyors note that the fire drill report form does not include that the fire alarm chime code was audible and could clearly be observed. The surveyors note that audible announcements from the switchboard are documented on the fire drill report forms (announcing the fire location with a code red and location) . Based upon testing of the fire alarm system on May 23, 2013, the surveyors observed that the fire alarm chime code is not loud enough to be heard in some areas. This is not being detected during fire drills and/or from testing of the fire alarm system (see also K051.

B. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2.

a. For the 11 pm to 7 am shift, fire drills are typically conducted separately in three of three health care building (include this East Building) between 4:00 am and 5:30 AM.

b. Whether the drill is being conduct for the 1st shift or the 2nd shift, the surveyor notes that fire drills are typically conducted, separately in three of three health care building (include this East Building), around 3:00 pm (usually during a shift change). The surveyor found other drills ar varying times for the 1st shift (7 am to 3 pm) but found no variation in time for the 2nd shift (3 pm to 11 pm)(always around 3:00 pm).

Based on random observation of fire alarm testing in four of four buildings on the morning of May 23, 2013, with multiple facilities personnel including the Senior Director of Facilities Management and the Director of Facilities Management, the surveyors find that not all portions of the facility's fire alarm systems are installed and maintained to comply with NFPA 72 - 1999.

Findings include but are not limited to:

1. During fire alarm testing the morning of 5/23/13 the surveyors find that audibility of the fire alarm in the Center Building was less than the 10 dBA above ambient noise an note in compliance with NFPA 72, 1999, 4-3.2.2.

a. The fire alarm chime code is not audible in the 1st Floor Admitting/Receiving area.

b. The fire alarm chime code is not audible throughout all portions of the 2nd Floor Imaging Department.





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2. Center Building 1st Floor Laboratory:

During fire alarm testing the morning of 5/23/13 in the company of a Facilities Management Representative the audibiity of the fire alarm was less than the 10 dBA above ambient noise as required by NFPA 72, 1999, 4-3.2.2.

Based on random observation of fire alarm testing in four of four buildings on the morning of May 23, 2013, with multiple facilities personnel including the Senior Director of Facilities Management and the Director of Facilities Management, the surveyors find that not all portions of the facility's fire alarm systems are installed and maintained to comply with NFPA 72 - 1999.

Findings include:

1. During fire alarm testing the morning of 5/23/13 the surveyors find that audibility of the fire alarm in the East Building was less than the 10 dBA above ambient noise an note in compliance with NFPA 72, 1999, 4-3.2.2.

a. The fire alarm chime code is not audible in the east end of the 1st Floor Emergency Department.

b. The fire alarm chime code is barely audible in portions of the Basement Level of the East Building.

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.This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

A. On the morining of May 21, 2013, smoke detectors at the following locations were located within 3' of supply air diffusers. These were confirmed with the VP of Ancillary Services and Director of Facilities Management.

1. Smoke detector in 3rd floor ICU

2. Smoke detector on 1st floor, near
room 107

B. On the morning of May 21, 2013, smoke detectors were not provided in areas that require smoke detection These were confirmed with the VP of Ancillary Services and Director of Facilities Management.

1. Dr.'s sleeping room off the back corridor
of the 3rd floor ICU suite.

2. Dr's sleeping room on the 2nd floor, next
to room 246.




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B. During fire alarm testing the morning of 5/23/13 in the company of a Facilities Management Representative the audibility of the fire alarm was less than the 10 dBA above ambient noise as required by NFPA 72, 1999, 4-3.2.2 at the following locations:

1. West Building 2nd Floor North Half of
Phychiatric Unit

2. West Building Basement North Wing

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, the surveyors find that not all portions of the building fire protection systems and materials are installed and maintained in accordance with NFPA 13 - 1999.

The East Building is identified as a fully sprinklered building.

Findings include but are not limited to:

A. Sprinkler head escutcheons were observed to be missing throughout many portions of sprinklered areas. Locations include but are not limited to:

1. 3rd Floor Offices in Suite 308

2. 1st Floor Emergency Department

Clean Utility Room

Janitor's Closet opposite nurses station wall.

B. Missing ceiling tiles and/or holes and voids in ceilings compromised sprinkler protection in multiple locations, including but not limited to

1. 3rd Floor Janitor's Closet: The sprinkler head escutcheon is missing. Part of the ceiling is missing; there is large hole in the soffit. The room is open to the ceiling cavity above and sprinkler protection in this room is compromised.

2. 3rd Floor Suite 300, Suite 302 and Suite 303

3. 2nd Floor Radiology Control Room

4. 1st Floor Emergency Room Entrance vestibule next to Waiting Room

C. Sprinkler heads lack 18" of clearance and/or are blocked by storage:

1. 3rd Floor Suite 314 - sprinkler head in closet.

2. 2nd Floor Suite 202 - sprinkler head in closet

D. The sprinkler system is not installed in compliance with NFPA 13:

1. The 1st Floor Inspector's Test Valve lacks identification.

2. Basement Mechanical Space: There are multiple sprinkler drains that lack identification.

3. The Basement Level has a sprinkler control valve and a flow switch for the basement zone. The provider was not able to locate a complying inspector's test valve for this zone.

4. The 3rd and 2nd Floor sprinkler inspector's test valves drain into a Basement sink with no air gap in accordance with NFPA 13 and the State Plumbing Code.

5. The Basement Closet with TS3 and TSI is not sprinklered and does not comply with NFPA 13 exceptions for unsprinklered spaces.



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E. East Building Basement:

Based on direct observation the afternoon of 5/22/13 in the company of a Facilities Management Technician, the surveyor finds the facility failed to provide:

1. Automatic sprinkler protection for the hydraulic elevator machine room. (NFPA 13, 1999, 5-13.6)

2. Automatic sprinkler protection for the hydraulic elevator hoistway pit in compliance with NFPA 13, 1999, 5-13.6.1. The sprinkler heads are installed more than the required 2 feet above the floor of the pit.

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, the surveyors find that not all portions of the building fire protection systems and materials are installed and maintained in accordance with NFPA 13 - 1999.

The Center Building is identified as a fully sprinklered on the 4th Floor and the 1st Floor.

Findings include but are not limited to:

A. Missing ceiling tiles, access panels left open and/or holes and voids in ceilings compromised sprinkler protection in multiple locations, including but not limited to

1. 4th Floor Soiled Utility Room (0418A) - open access panel in ceiling

2. 4th Floor Shower (0417C) - open access panel in ceiling

B. Sprinkler heads lack 18" of clearance and/or are blocked by storage:

1. Room 415 (Strategic National Stock Pile)

2. 2nd Floor Suite 202 - sprinkler head in closet

C. The sprinkler system is not installed in compliance with NFPA 13:

1. The 2nd Floor Pharmacy Closet (with the wood louvered door) is not sprinklered in an otherwise fully sprinklered space.

2. The 2nd Floor Pharmacy has a Director of Pharmacy office that lacks sprinkler protection in an otherwise fully sprinklered space.

3.. 1st Floor - north side of Center Building. There is an exterior open space under a new 2nd Floor "bridge" to an exit stair. This exterior space constitutes and building overhang that is used for combustible storage and it lack sprinkler protection in accordance with NFPA 13.

4. 1st Floor Outpatient Pharmacy Waiting Area - the sprinkler protection is installed no closer than 12'-0" from one wall and is not space in accordance with NFPA 13.

5. The Communication Closet with a pair of corridor doors opposite OPC Suite 1 is not sprinklered.

6. 1st Floor FastTrac Suite: The niche east of the nurse's station lacks sprinkler projection

D. Sprinkler head escutcheons were observed to be missing throughout many portions of sprinklered areas. Locations include but are not limited to:

1. 1st Floor Lab Bathroom

2. 1st Floor Admitting/Receiving Suite

3. 1st Floor Triage Copy Room

4. 1st Floor Triage and Triage II: escutcheons are missing in the Soiled Room, at the nurse's station and in most patient bays of this room.

5. 1st Floor FastTrac Suite: The niche east of the nurse's station lacks sprinkler protection.

The above items are not being detected and abated by the provider during monthly, quarterly and/or annual inspections and the above conditions are not cited in the annual documentation for inspection, maintenance and testing by outside contractors in accordance with NFPA 25.

A) Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 22, 2013, the surveyors find that fire barriers for vertical shaft enclosures and/or fire dampers are not installed and maintained in accordance with Section 19.5.2.1 and 9.2 of NFPA 101 - 2000 and NFPA 90 A - 1999. These condition could allow fire and smoke to spread beyond designated fire barriers during a fire emergency.

Findings include:

1. Center Building 3rd Floor Mechanical Room off oc Stair # 2: This room has a 12" round insulated duct (approx) that penetrates the floor near the west wall. The provider was unable to demonstrate that a fire damper and/or fire damper access panel was installed where the duct penetrates the floor.

2. The 1st Floor four hour vestibule between the East Building and the Center Building has a 4" round duct penetrating that floor above at or near the vestibule, above the ceiling. The provider was not able to demonstrate where and how a fire damper was installed where the duct penetrates the fire rated floor assembly above (or why a fire damper is not required.

3.. 1st Floor Phlebotomy: There is a duct and pipe chase at the east wall of this room. The chase is open to the ceiling cavity. The provider was not able to demonstrate why a fire rated shaft enclose is not required. The provider was not able to identify where the duct comes from and/or what is serves and was not able to demonstrate where fire damper(s) are installed.

4. Basement Level Center Building Bed Storage and Furniture Storage Room. There is a duct penetration in this room, roughly in the middle of the room through the floor above. The provider was not able to demonstrate how and where a fire damper is installed in accordance with NFPA 90A.

B) Based on random observation during the survey walk-through, with the Senior Director of Facilities Management, on May 22, 2013, the surveyors find that monitoring devices are not installed and maintained in accordance with the Hospital policies and/or CDC Guidelines.

Findings include:

1. Room 418 of the Center Building is identified as a patient isolation room. ON the afternoon of May 22, 2013, the surveyor observed that the room fan was set in the negative air pressure mode. The corridor door to the room was left open for more than five minutes and the electronic monitoring device would not go into alarm.

C. The 1st Floor Triage Copy Room has a portable cooling unit where the heat is exhausted into the ceiling cavity above instead of two an exhaust or return air duct.

D. Basement Level Center Building - There is a room that was identified as a Communication Room that had a washer and dryer in it and a sewage ejector or sump pump.

1. The dryer was not connected to an exhaust duct and the back half of the room was coated with lint. This condition constitutes a serious fire hazard and does not comply with CMS for Medicare requirements for dryers. The surveyor required that the dryer be disconnected immediately and that it be posted as "Do Not Use". until the lint has been abated and the dryer has been properly connected to a dryer exhaust duct.

2. There is a duct penetration in this room through the floor above. The provider was not able to demonstrate how and where a fire damper is installed in accordance with NFPA 90A.

Based on random observation during the survey walk-through, with the the Senior Director of Facilities Management, on May 22, 2013, the surveyor finds that some medical gas tanks are not stored in accordance with NFPA 99 - 1999.

Findings include:

1. 3rd Floor Center Building: The back Elevator Lobby (north lobby) has a storage room with oxygen tanks stored closer than 20' to combustibles. It is deficiencies and the 5' from combustibles rule does not apply because the space is not sprinklered.

2. 3rd Floor Surgical Suite: Room E3381 has two oxygen tanks stored in the room on the afternoon of May 22, 2013, that were not stored in a rack of secured.

Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 21, 2013, the surveyors find that medical gas systems are not installed and maintained in accordance with NFPA 99 - 1999. This condition could result in a delay in shutting off medical gasses in an emergency.

Findings include:

1. East Building 1st Floor Decontamination Room: The oxygen shut off valve in this room is labeled with signage which is faded and barely legible.

Based on random observation during the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

1. The 450 KW generator batteries were connected directly to the battery terminals, which is not in accordance with the requirements of the 1999 Edition of NFPA-110, Section 5-12.6.

Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Distribution panel EMDP, (the life safety distribution panel), is serving isolation panels IP1, IP2, and IP3 which are required by NFPA-70, Section 517-33, to be served by the critical branch of the emergency power system. Each branch of the emergency electrical system served by this generator shall be served from its' own transfer switch to meet the requirements of NFPA-70, Section 517-30.

Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Transfer switch TS3 serves life safety distribution panel EMDP, which serves both life safety and critical panels. Each branch of the emergency electrical system served by this generator shall be served from its' own transfer switch to meet the requirements of NFPA-70, Section 517-30.

Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Generator 147, in room N-179, serves transfer switch TS-2 which is serving a distribution panel that serves a fire alarm auxiliary panel that is a life safety load, and isolation panels that are critical loads. Transfer switch TS-4 serves a combination of equipment and critical loads. Each branch of the emergency electrical system served by this generator shall be served from its' own transfer switch to meet the requirements of NFPA-70, Section 517-30. The loads served by each transfer switch shall be in accordance with NFPA-70, Section 517-32 (life safety), 517-33 (critical), and 517-34 (equipment).

Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include:

1. The mechanical room accessed from the stairwell off of the OR corridor had seven isolation panels that were labeled as being served from the life safety panel. NFPA-70, Section 517-33 requires isolation panels served from emergency power to be on the critical branch, and Section 517-32 does not allow these panels to be served from the life safety branch of emergency power.

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management , on May 22, 2013, the surveyors find that not all portions of the building electrical systems and materials are installed in accordance with NFPA 70 1999.

Findings include:

A. Electrical extension cords were observed in use as prohibited by NFPA 70 1999 240-4 regarding wire size and NFPA 70 1999 305-3 regarding duration of use. Unapproved use of electrical extension cords could cause a fire. Locations observed include:

1st Floor Kitchen under the patient food preparation conveyor

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, the surveyors find that not all portions of the building electrical systems and materials are installed in accordance with NFPA 70 1999.

Findings include:

A. Electrical panels were observed that are not provided with accurate panel labels, circuit numbers and/or directories in accordance with NFPA 70 1999 384-13. Failure to properly identify electrical systems and components could delay response in an emergency.
Locations observed include but are not limited to:

1. 4th Floor East Building Electrical Closet in Janitor Room

Panel "PH1 EX FANS" has 19 of 19
circuits with no panel schedule

Panel "3002 SECTION" has no circuit
numbers that are visible in the lighting
available and 11 of 42 circuits are
labeled

Panel "33002 SECTION 2" and Panel
33003 both have similar conditions to
those cited above.

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, the surveyors find that portions of the building electrical systems and materials are not installed and maintained in accordance with NFPA 70 1999.

Findings include:

A. Electrical panels were observed that are not provided with accurate panel labels, circuit numbers and/or directories in accordance with NFPA 70 1999 384-13. Failure to properly identify electrical systems and components could delay response in an emergency. Locations observed include but are not limited to:

1. 3th Floor Center Building "back" elevator foyer with access to locker rooms.

a. In the elevator foyer (or in the adjacent
storage room): The electrical panels
lacks panel identification and access to
the panel is blocked by storage. 3'-0" of
clear space is not provided and
maintained.

b. The Dialysis Storage Room has a
electrical disconnect with no
identification.

c. The Dialysis Storage Room has an
electrical panel with no panel
identification. The panel has no visible
circuit numbers and circuit identification
is written in pencil.

2. 2nd Floor Pharmacy Closet (with louvered doors):

a. The closet has an has a electrical
disconnect with no identification.

b. The closet has has an electrical panel
with no panel identification. The panel
has no visible circuit numbers.

3. An electrical panel in the west end of Radiology lacks panel identification.

4. There is a large Square D electrical panel in the Radiology aisle that was not locked and panel lacks panel identification.

5. Old radiology Dark Room: There is an electrical panel that is hidden behind that door when the door is open. Signage is missing that identifies that electrical panel with the door open.

B. Electrical extension cords were observed in use as prohibited by NFPA 70 1999 240-4 regarding wire size and NFPA 70 1999 305-3 regarding duration of use. Unapproved use of electrical extension cords could cause a fire. Locations observed include:

1. 2nd Floor Radiology Reading Room - orange extension cord

2. 1st Floor Lab ISOTEMP 210021 Refrigerator on extension cord

3. The Basement Level Phone Room has equipment on an extension cord

C. The Basement Level Communication Room with sump pump (or sewage ejector) has water and wet rags on the floor for over 30% of the room with wall mounted electrical equipment adjacent. The provider was not able to identify the source of the water. This constitutes an unnecessary electrical hazard and it must be abated or corrected immediately.







17659


B. Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Normal power receptacles were not provided in the operating rooms, and the recovery rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power these rooms could be left with no power.

2. Receptacles in the OR's and recovery area need to be labeled with the circuit number and panelboard supplying them in accordance with NFPA-70, Section 517-19.

3. Critical receptacles are not provided in general care rooms in accordance with NFPA-70, Section 517-18.

4. The mechanical room accessed from the stairwell off of the OR corridor had an unmarked electrical panel that did not have a panel schedule and did not meet the requirements of NFPA-70, Section 110-22. This same mechanical room had seven isolation panels that did not have proper working clearance in accordance with NFPA-70, Section 110-26.

Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Normal power receptacles were not provided in the c-section rooms, and the nursery as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power these rooms could be left with no power.

2. Receptacles in the c-section room and nursery area need to be labeled with the circuit number and panelboard supplying them in accordance with NFPA-70, Section 517-19.

3. Critical receptacles are not provided in general care rooms in accordance with NFPA-70, Section 517-18.

4. The metal piping systems, (med gas and gas), are not bonded as required by NFPA 70-250.104(c). This could create a shock hazard for all building occupants.

5. Several panel schedules such as EMB-2 and the essential equipment panel in the boiler room were missing, handwritten, or not current and did not meet the requirements of NFPA-70, Section 110-22.

Based on random observation during the survey walk-through with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, and based on staff interview of the same personnel and based on random document review of monthly testing, the surveyor finds that all elevators within the facility do not conform with firefighters' recall requirements of ANSI/ASME A17.1/A17.3.

Failure to test and maintain elevator functions in accordance with ANSI/ASME A17.1/A17.3 could result in failure in a fire emergency. Failure to install and maintain emergency elevator functions in accordance with ANSI/ASME A17.1/A17.3 will result in loss of use by the Fire Department during a fire emergency.

Findings include:

East Building - Elevator # 7 serves four floors

A. The provider had no documentation that identifies annual testing and maintenance of Elevator # 7, including Phase I and Phase II fire fighters recall.

B. Elevator lobbies were observed to lack smoke detectors which comply with 19.5.3., 9.4.3.2., ANSI/ASME A17.3 1993 3.11.3. and ANSI/ASME A17.1 1993 211.3(b).

C. Elevator machine rooms were observed which lack smoke detectors required by ANSI/ASME A17.1 1993 211.3(b) and NFPA 72 1999 3-9.3.2.



17659

Based on random observation during the survey walk-through while accompanied by the Senior Director of Facilities Management, the surveyor found that 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. A single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation of each elevator is not provided as required by NFPA-70, Section 620-53.

2. The disconnect for the emergency lighting and controls for each elevator was not fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

3. The surveyor observed that the hydraulic elevator machine room was not equipped with sprinklers as required, and therefore was not a equipped with a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

Based on random observation during the survey walk-through with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, and based on staff interview of the same personnel and based on random document review of monthly testing, the surveyor finds that all elevators within the facility do not conform with firefighters' recall requirements of ANSI/ASME A17.1/A17.3.

Failure to test and maintain elevator functions in accordance with ANSI/ASME A17.1/A17.3 could result in failure in a fire emergency. Failure to install and maintain emergency elevator functions in accordance with ANSI/ASME A17.1/A17.3 will result in loss of use by the Fire Department during a fire emergency.

Findings include:

A. Center Building - Elevator # 1, and 2, serve four floors, Elevator 3, 4 & 5 serve six floors

The provider had no documentation that identifies monthly and annual testing and maintenance of all elevators including Phase I and Phase II fire fighters recall. The documentation available onsite (one page on red cardboard for multiple years) identifies compliance, monthly, with Phase I and Phase II requirements of ANSI/ASME A17.1/A17.3. However:

1. The documentation fails to identify specific testing for each elevator.

2. The documentation fails to identify the primary fire department designated floor of recall and the alternate floor.

3. The documentation identifies testing and compliance; however, most if not all elevator lobbies and elevator machine rooms lack smoke detection in accordance with ANSI/ASME A17.1/A17.3. Elevator recall functions on May 23, 3013 could not be tested with the surveyors present due to the lack of complying smoke detectors.

B. Elevator lobbies were observed to lack smoke detectors which comply with 19.5.3., 9.4.3.2., ANSI/ASME A17.3 1993 3.11.3. and ANSI/ASME A17.1 1993 211.3(b).

Note: elevator lobbies occur on both sides of some elevators on some floors. All lobbies lack smoke detection.

C. Elevator machine rooms were observed which lack smoke detectors required by ANSI/ASME A17.1 1993 211.3(b) and NFPA 72 1999 3-9.3.2.

D. The 6th Floor Elevator Machine Room is used for storage. The room lacks sprinkler protection and therefore does not comply with ANSI/ASME A17.1/A17.3 with storage in the machine room.


17659


B. Based on random observation during the survey walk-through while accompanied by the Senior Director of Facilities Management, the surveyor found that 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. A single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation of each elevator is not provided as required by NFPA-70, Section 620-53.

2. The disconnect for the emergency lighting and controls for each elevator was not fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

Based on random observation during the survey walk-through with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, and based on staff interview of the same personnel and based on random document review of monthly testing, the surveyor finds that all elevators within the facility do not conform with firefighters' recall requirements of ANSI/ASME A17.1/A17.3.

Failure to test and maintain elevator functions in accordance with ANSI/ASME A17.1/A17.3 could result in failure in a fire emergency. Failure to install and maintain emergency elevator functions in accordance with ANSI/ASME A17.1/A17.3 will result in loss of use by the Fire Department during a fire emergency.

Findings include:

North Building - Elevator # 6 serves five floors

A. The provider had no documentation that identifies monthly and annual testing and maintenance of Elevator # 6, including Phase I and Phase II fire fighters recall.

B. Elevator lobbies were observed to lack smoke detectors which comply with 19.5.3., 9.4.3.2., ANSI/ASME A17.3 1993 3.11.3. and ANSI/ASME A17.1 1993 211.3(b).

C. Elevator machine rooms were observed which lack smoke detectors required by ANSI/ASME A17.1 1993 211.3(b) and NFPA 72 1999 3-9.3.2.


17659

Based on random observation during the survey walk-through while accompanied by the Senior Director of Facilities Management, the surveyor found that 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. A single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation of each elevator was not provided as required by NFPA-70, Section 620-53.

2. The disconnect for the emergency lighting and controls for each elevator was not fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

3. The surveyor observed that the elevator machine room was equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

A. Based upon random observation, document review (and the lack of documentation) and based upon interview of the Director of Facilities on May 21, 2013 and May 22, 2013, the surveyor finds that the East Building, the Center Building and the West Building are constructed with reinforced concrete structural systems. However, the provider lacks historical data, U L Design Numbers, and or other information which identifies the Construction Type of each Building as defined by NFPA 220. The provider is not able to demonstrate that each of the three buildings is at least Type II (222) construction, if not Type I (332) construction in accordance with 19.1.6.2.

B. Basement Level Center Building: The Bed Storage/Furniture Storage Room is ribbed slab concrete construction above with a monolithic plaster ceiling installed on the bottom of the concrete. This plaster ceiling has large voids in it. The provider lacks documentation that demonstrates how the floor assembly it at least two hour rated without the plaster ceiling.

A. Based upon random observation, document review (and the lack of documentation) and based upon interview of the Director of Facilities on May 21, 2013 and May 22, 2013, the surveyor finds that the East Building, the Center Building and the West Building are constructed with reinforced concrete structural systems. However, the provider lacks historical data, U L Design Numbers, and/or other information which identifies the Construction Type of each Building as defined by NFPA 220. The provider is not able to demonstrate that each of the three buildings is at least Type II (222) construction, if not Type I (332) construction in accordance with 19.1.6.2.

A. Based on random observation during fire alarm testing, with the the Senior Director of Facilities Management, on May 23, 2013, the surveyors find that some corridor doors are not installed and maintained in accordance with Chapter 7 and 19.7.2 of NFPA 101.

Findings include:

1. 3rd Floor West Building: The pair of smoke doors/suite doors to the ICU failed to close to latch upon activation of the fire alarm sytem, in accordance with 19.3.7.2 and 7.2.1.8.

a. The West Building Obstetrics/C-Section Unit has a pair of doors where and the automatic opening/hold open functions are these doors are not disabled when the fire alarm system is activated and the doors to not close to latch upon activation of the fire alarm system.



10130

Based on observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied. This was confirmed by the VP of Ancillary Services and Director of Facilities Management.

B. On the morining of May 21, 2013, the following doors to the exit access corridor did not latch.

1. 3rd floor soiled utility room

2. 3rd floor ICU doors to the corridor

Based on random observation during the survey walk-through, with the the Director of Facilities Management, on May 21, 2013, the surveyors find that some corridor doors are not installed and maintained in accordance with Chapter 7 and 19.7.2 of NFPA 101.

Multiple corridor doors and doors within suites are wedged open. The provider is not able to identify why many of these doors have self closing devices. This condition will allow smoke to spread to the corridor and delays staff response during fire drills and a fire emergency.

Findings include but are not limited to

1. East Building - Doors in most 3rd Floor corridors and suites, including but not limited to Suite 300 and 302.

2. East Building - Doors in 2nd corridors and suites, including but not limited to Suite 200.

Based on random observation during the survey walk-through, with the the Senior Director of Facilities Management, on May 22, 2013, and based on observation of fire alarm testing on May 23, 2013, the surveyors find that some corridor doors are not installed and maintained in accordance with Chapter 7 and 19.7.2 of NFPA 101.

Findings include:

1. TV Room 0418B has a corridor door with a louver in the door that is not permitted under 19.3.6.4.

2. 2nd Floor Center Building:

a. The Surgical Unit is identified as a suite. The pair of auto-open doors at the west end of the suite lack any kind of positive latching hardware and the automatic opening/hold open functions are these doors are not disabled when the fire alarm system is activated.

b. The Staff Break Room has a door that is located at the suite boundary. The door has positive latching hardware; however, the door is routinely propped open.

3. 1st Floor Center Building: The following areas have aluminum and glass corridor doors that do not have positive latching hardware in compliance with 19.3.6.3.2.

a. Corridor door to the Outpatient Pharmacy Waiting Area

b. Corridor door to Admitting/receiving area

c. Lab

4. Multiple 1st Floor corridor doors were wedged open in both corridors and within suite and do not comply with 19.3.6.3.3.

a. Multiple doors inside Admitting/receiving.

b. Multiple corridor doors for OPWC

5. Basement Level corridor doors lack functioning positive latching hardware in accordance with 19.3.6.3.2:

a. Both Women's Locker Rooms

b. Mens Locker Room

5.

B. Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 22, 2013, the surveyors find that vertical openings are not protected and fire barriers are not installed and maintained in accordance with 8.2.5.6, 19.3.1.1 of NFPA 101 - 2000. These condition could allow fire and smoke to spread floor to floor and beyond designated fire barriers during a fire emergency.

Findings include:

1. 5th Floor four hour vestibule between the Center Building and the North Building: A construction project has resulted in the installation of new 4" conduits through the fire rated floor assembly and and through both fire barriers of the vestibule, with large holes and voids around the conduit. The penetrations were not sealed, either temporarily or permanently with fire rated materials in accordance with a U L Design (or equivalent).

The provider also failed to implement adequate interim life safety measures for this condition which would include observation, detection and abatement of the above condition.

2. 3rd Floor Center Building Surgical Suite - The Sterilizer Room next to O R # 7 has two sleeves through the fire rated floor into the space below that are not sealed for two hour fire rated construction.

3. 3rd Floor Center Building Surgical Suite - The Sterilizer Room next to O R # 7 has two duct penetrations into the the fire rated floor without fire dampers installed in accordance with NFPA 90A.

4. 3rd Floor Center Building Surgical Suite - The closet next to O R # 2 has two sleeves through the fire rated floor into the space below that are not sealed for two hour fire rated construction.

5. Basement Level Center Building: The elevator shaft for elevators # 1 and # 2 are open, at the elevator pit at the Basement Level, to an adjacent shaft to the west. The adjacent shaft enclosure has an access door in the elevator lobby at the basement Level that is not fire rated and self closing.






10130

Based on random observation during the survey walk through while accompanied by engineering staff, not all vertical openings are protected to comply with 19.3.1 and 8.2.5.2. This could contribute to the lack of containment during a fire event. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass between building stories.

A. On the afternoon of May 21, 2013, the provide was installing an additional elevator and an adjacent utiltiy chase. The opening to this vertical shaft was sealed with 1 layer of drywall and metal hat channels. No interim measures were in place. This was confirmed witht eh VP of Ancillary Services and Director of Facilities Management

Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 22, 2013, the surveyors find that fire doors and/or doors that are required to be self closing are held open by means that do not comply with 7.2.1.8 of NFPA 101 - 2000. These conditions could allow fire and smoke to spread during a fire emergency.

Findings include:

1. 3rd Floor Center Building Surgical Suite: There is a pair of designated smoke doors with hold open devices in this suite. The door hold open devices do not release automatically from activation of the fire alarm system. (confirm local smoke detection also)

2. Basement Level Center Building - The Housekeeping Storage Room near Stair # 4 has a corridor door with a magnetic hold open device. A smoke detector is not installed on both sides of this door.

3. Basement Level Center Building - The Linen Room has a a pair of corridor doors with magnetic hold open devices. A smoke detector is not installed on both sides of these doors in accordance with NFPA 72.

Based on renadom observation, exit signs are not located to identify the path of exit. This could affect all residents, staff and visitors who may need to evacuate the building in a timely manner if they are not able to readily identify the pathe of exit.

A. On the afternoon of May 21, 2013, the secondary exit from the Womens Psychatric Unit was not identified by an exit sign. This was confirmed with the VP of Ancillary Services and Director of Facilities Management.

Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 22, 2013, the surveyors find that required smoke barriers are not installed and maintained in accordance with 19.3.7.3 of NFPA 101 - 2000. These condition could allow fire and smoke to spread beyond designated fire/smoke barriers during a fire emergency.

Findings include:

1. (4 - Center Building) The designated one hour smoke barrier roughly in the middle of the 4th Floor of the Center Building has a cable penetration above the ceiling which was not sealed for fire rated construction.

2. (4 - Center Building) The designated one hour smoke barrier roughly in the middle of the 4th Floor of the Center Building has a void in the smoke barrier, as viewed above the ceiling from the Kitchenette, looking to the southwest.

3. (2 - Center Building) The 2nd Floor designated one hour smoke barrier near the elevator and above a pair of opposite swinging doors has a duct penetration above the ceiling that is not sealed as a smoke tight penetration through the smoke barrier.

4. (Bsmt - Center Building) The designated one hour smoke barrier at the Basement Level of the Center Building has a penetration above the ceiling, above a pair of smoke doors, which was not sealed for fire rated construction. The drywall barrier above the ceiling has joints that are not sealed/taped in accordance with a U L Design Number for a one hour barrier.

Based on random observation during the survey walk-through, with the the Senior Director of Facilities Management, on May 22, 2013, the surveyor finds that some hazardous areas are not enclosed in accordance with 19.3.2.1 and 8.4.1 of NFPA 101.

Findings include:

1. 4 - Center: Strategic National Stoke Pile Room 415 has a corridor door that lacks self closing hardware.

2. 3rd Floor Center Building Surgical Suite: This floor is not fully sprinklered (information only)

a. A storage room with a south door to the
aisle inside the suite lacks positive
latching hardware (the latchset has been
removed).

b. Storage Room E3303 is a hazardous
area with a door to a dialysis room. This
door is not fire rated, the glazing in the
door is not fire rated and the door is not
self closing.

c. The former Anesthesia Office, now
storage room, has a door which lacks a
3/4 hour fire rating and self closing
hardware.

d. Operating Room 5 and 6 have been
converted to storage rooms. The
doors to these rooms are not 3/4
hour fire rated doors. The door to
O R # 5 also hangs up on the floor
and does not close to latch. The
door to O R # 6 has a built in
manual hold open device which
does not comply with 7.2.1.8.

e. Sterile Instrument Storage Room
E3317 and Room E3326 - the
doors to these rooms do not
close to latch.

3. The 2nd Floor Back (north) Elevator Foyer has two closets in the west side of the space that are full of combustibles. The rooms lack one hour fire rated enclosure and the doors are not 3/4 hour fire rated doors with self closing hardware.

4. The 2nd Floor Pharmacy Storage Room has a latchset that has been disabled.

5. The provider is not able to demonstrate how the 2nd Floor Pharmacy is not a hazardous area and how is it separated from the Elevator Foyer to the South with a one hour fire barrier.

6. The 2nd Floor Imaging Department has an old Dark Room that is full of combustibles and debris. The door to this room is not a 3/4 hour fire rated door with positive latching hardware.

7. The Basement Level Morgue Elevator Machine Room has a louvered door. The louver is not permitted under 19.3.2.1 and 19.3.6.4.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with NFPA 101-2000, 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

1. On the afternoon of May 21, 2013, Room 246 (across from the psychiatric unit) was found to contain file storage in quantity that would be considered hazardous. The room was sprinklered, but the door was not self closing. This was confirmed with the VP of Ancillary Services and Director of Facilities Management.

Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 21, 2013, the surveyors find that required exit stairs are not installed and maintained in accordance with Chapter 7 and 19.2 of NFPA 101 - 2000. This condition reduces the exit capacity of this stair in an emergency and could result in loss of the exit in a fire emergency.

Findings include:

1. Stair # 3 (East Exit Stair), at the 3rd Floor, has a large wall mounted metal electrical box that extends the length of the east wall of this stair.

a. The box is part of the electrical wiring for a sign mounted on the exterior wall of the stair and is not permitted under 7.1.3.2.1. e) and and 7.2.2.5.3 of NFPA 101.

b. The metal box projects 8" or more into the required exit width of the stair at the 3rd Floor landing and fhe first five to six steps.

2. East Building Stair # 8 has duct penetrations (large duct) through to walls of the stair enclosure, at the 1st Floor above a soffit in the stair. The provider lacks detailed information and photographs that demonstrate how the soffit was constructed as a two hour fire barrier and there are no access panels in the walls above the soffit (note - access panels are not permitted within the stair.

a. The surveyor observed that one duct penetration is installed with a fire damper, however there is a hole or void in the wall around the fire damper.

b. The 2nd duct penetration has no fire damper.

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management , on May 22, 2013, the surveyors find that exit stair enclosures are not installed and maintained in accordance with Chapter 7 and Chapter 8 of NFPA 101 - 2000. Failure to maintain fire separations for exit stairs could result in loss of use in a fire emergency.

Findings include:

1. 1st Floor North Building - Boiler Plant Building and old Laundry Room portion of North Building:

a. Exit Stair # 11 has a stair door with U L Labels that cannot be read. A fire rated B Label door was not found.

b. Exit Stair # 12 is a two story stair. The 1st Floor door to the stair has hardware that can be disabled so that the door does not latch. The door is typically not latched and the specific hardware identified is not permitted on a fire door.

c. Exit Stair # 12 is a two story stair. The stair is supported by unprotected steel legs and angles that are located in an open niche off of a 1st Floor corridor. The support of this stair is not protected as a one hour fire rated assembly and the niche is used for storage.

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management , on May 22, 2013, the surveyors find that exit stair enclosures are not installed and maintained in accordance with Chapter 7 and Chapter 8 of NFPA 101 - 2000. Failure to maintain fire separations for exit stairs could result in loss of use in a fire emergency.

Findings include:

1. The 1st Floor stair door to Exit Stair # 10 has a U L Label that cannot be read. A fire rated B Label door was not found.


2. The Basement stair door to Exit Stair # 10 does not close to latch.

Based on observation during the survey walk-through, not all exit stairs are constructed in accordance with the requirements of 19.2.2.3 & 7.2.2. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by impeding the use of the stairs during building exiting.

A. On the morning of May 21, 2013, the exit star guard rail spacing was larger than the permitted per Section 7.2.2.4.6.

1. Stair #4

2. Stair #5

3. Stair #6

4. Based on the non-compliance of the
guardrail spacing in 3 out of 3 stairs
within the West Building, the remaining
guard rail spacing in all exit stairs
within the facility must be verified. This
was confirmed with the VP of Ancillary
Services and Director of Facilities
Management.

A. Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 21, 2013, the surveyors find that exit stairs and exit paths are not installed and maintained in accordance with Chapter 7 of NFPA 101 - 2000. Exits are not readily available at all times. This condition result in a delay or confusion during the exit process in a fire emergency.

Findings include

1. Exit stairs which continue beyond the level of exit discharge were observed that are not equipped with interrupter gates required by 7.7.3. Locations observed include: Stair # 8 continues to the Basement Level, past the level of exit discharge without a complying interruption.

2. East Building 1st Floor: The east exit door to the outside (with an exit sign) is locked with a magnetic locking device that does not comply with 7.2.1.6.1 or 7.2.1.6.2 and 19.2.2.2.4. The location does not qualify for the use of Exception # 1 under 19.2.2.2.4

B. The 1st Floor has two pairs of existing fire doors marked as an exit path between the East Building to the Center Building. There are no signs on the doors which identify which door must be pulled open in order to exit through the pair of doors to the east.

Based on random observation during the survey walk-through, with the the Senior Director of Facilities Management, on May 22, 2013, the surveyor finds that some exit accesses are not arranged so that exit paths are readily accessible at all times in accordance with 19.2.1.

Findings include:

1. 1st Floor Outpatient Pharmacy. The corridor door to this pharmacy is partially obstructed by a metal locked inside the Pharmacy.

Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with Sections 19.2.1 and 7.2.1.6.1.. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

A. On the morning of May 22, 2013, the OB unity was found to have magnetic locking devices on exits doors that did not release within a certain time frame when pressure was applied to the door. The doors required special knowledge (keypad code) to open the door or a remote release switch at the nurse station. The occupants of the mother/baby unit do not have any clinical need to prevent their egress. This was confirmed with the VP of Ancillary Services and Director of Facilities Management.

Based on observation during fire alarm testing, with the Director of Facilities Management, on the morning of May 23, 2013, the surveyors find that fire barriers are not installed and maintained in accordance with Chapter 7.2.4 of NFPA 101 - 2000. These condition could allow fire and smoke to spread beyond designated fire barriers during a fire emergency.

Findings include

1. West Building 3rd Floor, one door of two pairs of fire doors near Room 337 failed to latch.


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Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, because failure to construct and maintain fire resistive assemblies could allow fire and smoke to pass from one compartment into adjacent fire/smoke compartments.

A. The door coordinators did not function properly and doors would not close to latch.

1. On the morning of May 21, 2013, both cross corridor doors located in the "Chicago vestibule" near the elevator lobby on the 3rd floor did not latch to close. This was confirmed with the VP of Ancillary Services and Director of Facilities Management.

2. On the morning of May 21, 2013, one of the cross corridor doors located in the "Chicago vestibule" near the elevator lobby on the 2nd floor did not latch to close. This was confirmed with the VP of Ancillary Services and Director of Facilities Management.

3. On the afternoon of May 21, 2013, the pair of cross corridor doors to the chemical dependance unit on the 2nd floor was not equipped with a coordinator. This was confirmed with the VP of Ancillary Services and Director of Facilities Management.

Based on observation during the survey walk-through, with the Director of Facilities Management, on May 22, 2013, the surveyors find that fire barriers are not installed and maintained in accordance with Chapter 7.2.4 of NFPA 101 - 2000. These condition could allow fire and smoke to spread beyond designated fire barriers during a fire emergency.

Findings include:

1. The 1st Floor four hour vestibule between the East Building and the Center Building has a cable penetration above the fire doors, above the ceiling, that is not sealed for fire rate construction.

A. The provider furnished Life Safety Plans as information to be used for the survey. The small scale plans dated 2007 were used for 90% of the survey. There is no indication that these small scale plans match completely a large set of plans dated 2010. Based on direct observation and document review the surveyors find the plans provided are not accurate for portions of the building.

Findings include;

1. 3rd Floor Center Building - the west end of the building is not shown accurately. The back elevator foyer (north foyer is used as as storage or holding area and is not identified on plans as a hazardous area with a one hour enclosure.

2. The 2nd Floor new CT Scan Room and nearby areas have not been updated on the Life Safety Plans.

3. The 1st Floor plans show a walk through from the Main Waiting Area into the elevator foyer north of elevators # 1 and # 2. The walk through opening does not exist.

4. The plans dated 2010 use a large dashed red line to identify four hour barriers in the plan key. However, the plans use a smaller dashed red line that does not match the plan key and the designations are not clearly identified.

Based on document review of fire drills records for the previous five months and a random review of records for the previous twelve months and based upon interview of administrative and facilities personnel, including Director of Facilities Management, on May 23, 2013, the surveyors find that fire drills are not always conducted at varying times and varying conditions in accordance with 19.7.1.2.

The surveyors note that the fire alarm system for each of the four buildings are independent of the other building and that fire drills are documented on in the building of activation.

Findings include:

A. Based on document review and random observation, the surveyors note that the fire drill report form does not include that the fire alarm system was audible in the area observed and that the chime code was audible and could clearly be observed. The surveyors note that audible announcements from the switchboard are documented on the fire drill report forms (announcing the fire location with a code red and location) . Based upon testing of the fire alarm system on May 23, 2013, the surveyors observed that the fire alarm chime code is not loud enough to be heard in some areas. This is not being detected during fire drills and/or from testing of the fire alarm system (see also K051.

B. Based upon document review the surveyor finds that a minimal number of fire drills are conducted for each shift for each quarter. Only a portion of each health care floor is observed for each shift each quarter. Example: A fire drill was conducted in one of three smoke compartments of teh West Building at 3:09 pm on March of 2013. The same smoke compartment on the same floor was observed and documented by an observer and the nurse in charge on the unit. The two other health care smoke compartments on the same floor and the six other smoke compartments were not observed or documented.

Out of nine of nine health care occupied smoke compartments in this building, only one of nine receives an observed fire drill, each shift in a three month period.

C. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2.

a. For the 11 pm to 7 am shift, fire drills are typically conducted separately in three of three health care building (include this West Building) between 4:00 am and 5:30 AM.

b. Whether the drill is being conduct for the 1st shift or the 2nd shift, the surveyor notes that fire drills are typically conducted, separately in three of three health care building (include this West Building), around 3:00 pm. The surveyor found other drills ar varying times for the 1st shift (7 am to 3 pm) but found no variation in time for the 2nd shift (3 pm to 11 pm).(3:00 pm only)

Based on document review of fire drills records for the previous five months and a random review of records for the previous twelve months and based upon interview of administrative and facilities personnel, including Director of Facilities Management, on May 23, 2013, the surveyors find that fire drills are not always conducted at varying times and varying conditions in accordance with 19.7.1.2.

The surveyors note that the fire alarm system for each of the four buildings are independent of the other building and that fire drills are documented on in the building of activation.

Findings include:

A. Based on document review and random observation, the surveyors note that the fire drill report form does not include that the fire alarm system was audible in the area observed and that the chime code was audible and could clearly be observed. The surveyors note that audible announcements from the switchboard are documented on the fire drill report forms (announcing the fire location with a code red and location) . Based upon testing of the fire alarm system on May 23, 2013, the surveyors observed that the fire alarm chime code is not loud enough to be heard in some areas. This is not being detected during fire drills and/or from testing of the fire alarm system (see also K051).

B. Based upon document review the surveyor finds that a minimal number of fire drills are conducted for each shift for each quarter. Only a portion of each health care floor is observed. A fire drill is typically conducted in one of two smoke compartments on the same floor. The other health care smoke compartment on the same floor and the six other smoke compartments on three other floors were not observed or documented.

C. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2.

a. For the 11 pm to 7 am shift, fire drills are typically conducted separately in three of three health care building (include this Center Building) between 4:00 am and 5:30 AM.

b. Whether the drill is being conduct for the 1st shift or the 2nd shift, the surveyor notes that fire drills are typically conducted, separately in three of three health care building (include this Center Building), around 3:00 pm. The surveyor found other drills ar varying times for the 1st shift (7 am to 3 pm) but found no variation in time for the 2nd shift (3 pm to 11 pm) (3:00 pm only).

Based on document review of fire drills records for the previous five months and a random review of records for the previous twelve months and based upon interview of administrative and facilities personnel, including Director of Facilities Management, on May 23, 2013, the surveyors find that fire drills are not always conducted at varying times and varying conditions in accordance with 19.7.1.2.

The surveyors note that the fire alarm system for each of the four buildings is independent of the other building and that fire drills are documented only in the building of activation.

Findings include:

A. Based on document review and random observation, the surveyors note that the fire drill report form does not include that the fire alarm chime code was audible and could clearly be observed. The surveyors note that audible announcements from the switchboard are documented on the fire drill report forms (announcing the fire location with a code red and location) . Based upon testing of the fire alarm system on May 23, 2013, the surveyors observed that the fire alarm chime code is not loud enough to be heard in some areas. This is not being detected during fire drills and/or from testing of the fire alarm system (see also K051.

B. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2.

a. For the 11 pm to 7 am shift, fire drills are typically conducted separately in three of three health care building (include this East Building) between 4:00 am and 5:30 AM.

b. Whether the drill is being conduct for the 1st shift or the 2nd shift, the surveyor notes that fire drills are typically conducted, separately in three of three health care building (include this East Building), around 3:00 pm (usually during a shift change). The surveyor found other drills ar varying times for the 1st shift (7 am to 3 pm) but found no variation in time for the 2nd shift (3 pm to 11 pm)(always around 3:00 pm).

Based on random observation of fire alarm testing in four of four buildings on the morning of May 23, 2013, with multiple facilities personnel including the Senior Director of Facilities Management and the Director of Facilities Management, the surveyors find that not all portions of the facility's fire alarm systems are installed and maintained to comply with NFPA 72 - 1999.

Findings include but are not limited to:

1. During fire alarm testing the morning of 5/23/13 the surveyors find that audibility of the fire alarm in the Center Building was less than the 10 dBA above ambient noise an note in compliance with NFPA 72, 1999, 4-3.2.2.

a. The fire alarm chime code is not audible in the 1st Floor Admitting/Receiving area.

b. The fire alarm chime code is not audible throughout all portions of the 2nd Floor Imaging Department.





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2. Center Building 1st Floor Laboratory:

During fire alarm testing the morning of 5/23/13 in the company of a Facilities Management Representative the audibiity of the fire alarm was less than the 10 dBA above ambient noise as required by NFPA 72, 1999, 4-3.2.2.

Based on random observation of fire alarm testing in four of four buildings on the morning of May 23, 2013, with multiple facilities personnel including the Senior Director of Facilities Management and the Director of Facilities Management, the surveyors find that not all portions of the facility's fire alarm systems are installed and maintained to comply with NFPA 72 - 1999.

Findings include:

1. During fire alarm testing the morning of 5/23/13 the surveyors find that audibility of the fire alarm in the East Building was less than the 10 dBA above ambient noise an note in compliance with NFPA 72, 1999, 4-3.2.2.

a. The fire alarm chime code is not audible in the east end of the 1st Floor Emergency Department.

b. The fire alarm chime code is barely audible in portions of the Basement Level of the East Building.

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.This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

A. On the morining of May 21, 2013, smoke detectors at the following locations were located within 3' of supply air diffusers. These were confirmed with the VP of Ancillary Services and Director of Facilities Management.

1. Smoke detector in 3rd floor ICU

2. Smoke detector on 1st floor, near
room 107

B. On the morning of May 21, 2013, smoke detectors were not provided in areas that require smoke detection These were confirmed with the VP of Ancillary Services and Director of Facilities Management.

1. Dr.'s sleeping room off the back corridor
of the 3rd floor ICU suite.

2. Dr's sleeping room on the 2nd floor, next
to room 246.




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B. During fire alarm testing the morning of 5/23/13 in the company of a Facilities Management Representative the audibility of the fire alarm was less than the 10 dBA above ambient noise as required by NFPA 72, 1999, 4-3.2.2 at the following locations:

1. West Building 2nd Floor North Half of
Phychiatric Unit

2. West Building Basement North Wing

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, the surveyors find that not all portions of the building fire protection systems and materials are installed and maintained in accordance with NFPA 13 - 1999.

The East Building is identified as a fully sprinklered building.

Findings include but are not limited to:

A. Sprinkler head escutcheons were observed to be missing throughout many portions of sprinklered areas. Locations include but are not limited to:

1. 3rd Floor Offices in Suite 308

2. 1st Floor Emergency Department

Clean Utility Room

Janitor's Closet opposite nurses station wall.

B. Missing ceiling tiles and/or holes and voids in ceilings compromised sprinkler protection in multiple locations, including but not limited to

1. 3rd Floor Janitor's Closet: The sprinkler head escutcheon is missing. Part of the ceiling is missing; there is large hole in the soffit. The room is open to the ceiling cavity above and sprinkler protection in this room is compromised.

2. 3rd Floor Suite 300, Suite 302 and Suite 303

3. 2nd Floor Radiology Control Room

4. 1st Floor Emergency Room Entrance vestibule next to Waiting Room

C. Sprinkler heads lack 18" of clearance and/or are blocked by storage:

1. 3rd Floor Suite 314 - sprinkler head in closet.

2. 2nd Floor Suite 202 - sprinkler head in closet

D. The sprinkler system is not installed in compliance with NFPA 13:

1. The 1st Floor Inspector's Test Valve lacks identification.

2. Basement Mechanical Space: There are multiple sprinkler drains that lack identification.

3. The Basement Level has a sprinkler control valve and a flow switch for the basement zone. The provider was not able to locate a complying inspector's test valve for this zone.

4. The 3rd and 2nd Floor sprinkler inspector's test valves drain into a Basement sink with no air gap in accordance with NFPA 13 and the State Plumbing Code.

5. The Basement Closet with TS3 and TSI is not sprinklered and does not comply with NFPA 13 exceptions for unsprinklered spaces.



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E. East Building Basement:

Based on direct observation the afternoon of 5/22/13 in the company of a Facilities Management Technician, the surveyor finds the facility failed to provide:

1. Automatic sprinkler protection for the hydraulic elevator machine room. (NFPA 13, 1999, 5-13.6)

2. Automatic sprinkler protection for the hydraulic elevator hoistway pit in compliance with NFPA 13, 1999, 5-13.6.1. The sprinkler heads are installed more than the required 2 feet above the floor of the pit.

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, the surveyors find that not all portions of the building fire protection systems and materials are installed and maintained in accordance with NFPA 13 - 1999.

The Center Building is identified as a fully sprinklered on the 4th Floor and the 1st Floor.

Findings include but are not limited to:

A. Missing ceiling tiles, access panels left open and/or holes and voids in ceilings compromised sprinkler protection in multiple locations, including but not limited to

1. 4th Floor Soiled Utility Room (0418A) - open access panel in ceiling

2. 4th Floor Shower (0417C) - open access panel in ceiling

B. Sprinkler heads lack 18" of clearance and/or are blocked by storage:

1. Room 415 (Strategic National Stock Pile)

2. 2nd Floor Suite 202 - sprinkler head in closet

C. The sprinkler system is not installed in compliance with NFPA 13:

1. The 2nd Floor Pharmacy Closet (with the wood louvered door) is not sprinklered in an otherwise fully sprinklered space.

2. The 2nd Floor Pharmacy has a Director of Pharmacy office that lacks sprinkler protection in an otherwise fully sprinklered space.

3.. 1st Floor - north side of Center Building. There is an exterior open space under a new 2nd Floor "bridge" to an exit stair. This exterior space constitutes and building overhang that is used for combustible storage and it lack sprinkler protection in accordance with NFPA 13.

4. 1st Floor Outpatient Pharmacy Waiting Area - the sprinkler protection is installed no closer than 12'-0" from one wall and is not space in accordance with NFPA 13.

5. The Communication Closet with a pair of corridor doors opposite OPC Suite 1 is not sprinklered.

6. 1st Floor FastTrac Suite: The niche east of the nurse's station lacks sprinkler projection

D. Sprinkler head escutcheons were observed to be missing throughout many portions of sprinklered areas. Locations include but are not limited to:

1. 1st Floor Lab Bathroom

2. 1st Floor Admitting/Receiving Suite

3. 1st Floor Triage Copy Room

4. 1st Floor Triage and Triage II: escutcheons are missing in the Soiled Room, at the nurse's station and in most patient bays of this room.

5. 1st Floor FastTrac Suite: The niche east of the nurse's station lacks sprinkler protection.

The above items are not being detected and abated by the provider during monthly, quarterly and/or annual inspections and the above conditions are not cited in the annual documentation for inspection, maintenance and testing by outside contractors in accordance with NFPA 25.

A) Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 22, 2013, the surveyors find that fire barriers for vertical shaft enclosures and/or fire dampers are not installed and maintained in accordance with Section 19.5.2.1 and 9.2 of NFPA 101 - 2000 and NFPA 90 A - 1999. These condition could allow fire and smoke to spread beyond designated fire barriers during a fire emergency.

Findings include:

1. Center Building 3rd Floor Mechanical Room off oc Stair # 2: This room has a 12" round insulated duct (approx) that penetrates the floor near the west wall. The provider was unable to demonstrate that a fire damper and/or fire damper access panel was installed where the duct penetrates the floor.

2. The 1st Floor four hour vestibule between the East Building and the Center Building has a 4" round duct penetrating that floor above at or near the vestibule, above the ceiling. The provider was not able to demonstrate where and how a fire damper was installed where the duct penetrates the fire rated floor assembly above (or why a fire damper is not required.

3.. 1st Floor Phlebotomy: There is a duct and pipe chase at the east wall of this room. The chase is open to the ceiling cavity. The provider was not able to demonstrate why a fire rated shaft enclose is not required. The provider was not able to identify where the duct comes from and/or what is serves and was not able to demonstrate where fire damper(s) are installed.

4. Basement Level Center Building Bed Storage and Furniture Storage Room. There is a duct penetration in this room, roughly in the middle of the room through the floor above. The provider was not able to demonstrate how and where a fire damper is installed in accordance with NFPA 90A.

B) Based on random observation during the survey walk-through, with the Senior Director of Facilities Management, on May 22, 2013, the surveyors find that monitoring devices are not installed and maintained in accordance with the Hospital policies and/or CDC Guidelines.

Findings include:

1. Room 418 of the Center Building is identified as a patient isolation room. ON the afternoon of May 22, 2013, the surveyor observed that the room fan was set in the negative air pressure mode. The corridor door to the room was left open for more than five minutes and the electronic monitoring device would not go into alarm.

C. The 1st Floor Triage Copy Room has a portable cooling unit where the heat is exhausted into the ceiling cavity above instead of two an exhaust or return air duct.

D. Basement Level Center Building - There is a room that was identified as a Communication Room that had a washer and dryer in it and a sewage ejector or sump pump.

1. The dryer was not connected to an exhaust duct and the back half of the room was coated with lint. This condition constitutes a serious fire hazard and does not comply with CMS for Medicare requirements for dryers. The surveyor required that the dryer be disconnected immediately and that it be posted as "Do Not Use". until the lint has been abated and the dryer has been properly connected to a dryer exhaust duct.

2. There is a duct penetration in this room through the floor above. The provider was not able to demonstrate how and where a fire damper is installed in accordance with NFPA 90A.

Based on random observation during the survey walk-through, with the the Senior Director of Facilities Management, on May 22, 2013, the surveyor finds that some medical gas tanks are not stored in accordance with NFPA 99 - 1999.

Findings include:

1. 3rd Floor Center Building: The back Elevator Lobby (north lobby) has a storage room with oxygen tanks stored closer than 20' to combustibles. It is deficiencies and the 5' from combustibles rule does not apply because the space is not sprinklered.

2. 3rd Floor Surgical Suite: Room E3381 has two oxygen tanks stored in the room on the afternoon of May 22, 2013, that were not stored in a rack of secured.

Based on observation during the survey walk-through, with the the Director of Facilities Management, on May 21, 2013, the surveyors find that medical gas systems are not installed and maintained in accordance with NFPA 99 - 1999. This condition could result in a delay in shutting off medical gasses in an emergency.

Findings include:

1. East Building 1st Floor Decontamination Room: The oxygen shut off valve in this room is labeled with signage which is faded and barely legible.

Based on random observation during the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

1. The 450 KW generator batteries were connected directly to the battery terminals, which is not in accordance with the requirements of the 1999 Edition of NFPA-110, Section 5-12.6.

Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Distribution panel EMDP, (the life safety distribution panel), is serving isolation panels IP1, IP2, and IP3 which are required by NFPA-70, Section 517-33, to be served by the critical branch of the emergency power system. Each branch of the emergency electrical system served by this generator shall be served from its' own transfer switch to meet the requirements of NFPA-70, Section 517-30.

Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Transfer switch TS3 serves life safety distribution panel EMDP, which serves both life safety and critical panels. Each branch of the emergency electrical system served by this generator shall be served from its' own transfer switch to meet the requirements of NFPA-70, Section 517-30.

Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Generator 147, in room N-179, serves transfer switch TS-2 which is serving a distribution panel that serves a fire alarm auxiliary panel that is a life safety load, and isolation panels that are critical loads. Transfer switch TS-4 serves a combination of equipment and critical loads. Each branch of the emergency electrical system served by this generator shall be served from its' own transfer switch to meet the requirements of NFPA-70, Section 517-30. The loads served by each transfer switch shall be in accordance with NFPA-70, Section 517-32 (life safety), 517-33 (critical), and 517-34 (equipment).

Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include:

1. The mechanical room accessed from the stairwell off of the OR corridor had seven isolation panels that were labeled as being served from the life safety panel. NFPA-70, Section 517-33 requires isolation panels served from emergency power to be on the critical branch, and Section 517-32 does not allow these panels to be served from the life safety branch of emergency power.

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management , on May 22, 2013, the surveyors find that not all portions of the building electrical systems and materials are installed in accordance with NFPA 70 1999.

Findings include:

A. Electrical extension cords were observed in use as prohibited by NFPA 70 1999 240-4 regarding wire size and NFPA 70 1999 305-3 regarding duration of use. Unapproved use of electrical extension cords could cause a fire. Locations observed include:

1st Floor Kitchen under the patient food preparation conveyor

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, the surveyors find that not all portions of the building electrical systems and materials are installed in accordance with NFPA 70 1999.

Findings include:

A. Electrical panels were observed that are not provided with accurate panel labels, circuit numbers and/or directories in accordance with NFPA 70 1999 384-13. Failure to properly identify electrical systems and components could delay response in an emergency.
Locations observed include but are not limited to:

1. 4th Floor East Building Electrical Closet in Janitor Room

Panel "PH1 EX FANS" has 19 of 19
circuits with no panel schedule

Panel "3002 SECTION" has no circuit
numbers that are visible in the lighting
available and 11 of 42 circuits are
labeled

Panel "33002 SECTION 2" and Panel
33003 both have similar conditions to
those cited above.

Based on random observation during the survey walk-through, with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, the surveyors find that portions of the building electrical systems and materials are not installed and maintained in accordance with NFPA 70 1999.

Findings include:

A. Electrical panels were observed that are not provided with accurate panel labels, circuit numbers and/or directories in accordance with NFPA 70 1999 384-13. Failure to properly identify electrical systems and components could delay response in an emergency. Locations observed include but are not limited to:

1. 3th Floor Center Building "back" elevator foyer with access to locker rooms.

a. In the elevator foyer (or in the adjacent
storage room): The electrical panels
lacks panel identification and access to
the panel is blocked by storage. 3'-0" of
clear space is not provided and
maintained.

b. The Dialysis Storage Room has a
electrical disconnect with no
identification.

c. The Dialysis Storage Room has an
electrical panel with no panel
identification. The panel has no visible
circuit numbers and circuit identification
is written in pencil.

2. 2nd Floor Pharmacy Closet (with louvered doors):

a. The closet has an has a electrical
disconnect with no identification.

b. The closet has has an electrical panel
with no panel identification. The panel
has no visible circuit numbers.

3. An electrical panel in the west end of Radiology lacks panel identification.

4. There is a large Square D electrical panel in the Radiology aisle that was not locked and panel lacks panel identification.

5. Old radiology Dark Room: There is an electrical panel that is hidden behind that door when the door is open. Signage is missing that identifies that electrical panel with the door open.

B. Electrical extension cords were observed in use as prohibited by NFPA 70 1999 240-4 regarding wire size and NFPA 70 1999 305-3 regarding duration of use. Unapproved use of electrical extension cords could cause a fire. Locations observed include:

1. 2nd Floor Radiology Reading Room - orange extension cord

2. 1st Floor Lab ISOTEMP 210021 Refrigerator on extension cord

3. The Basement Level Phone Room has equipment on an extension cord

C. The Basement Level Communication Room with sump pump (or sewage ejector) has water and wet rags on the floor for over 30% of the room with wall mounted electrical equipment adjacent. The provider was not able to identify the source of the water. This constitutes an unnecessary electrical hazard and it must be abated or corrected immediately.







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B. Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Normal power receptacles were not provided in the operating rooms, and the recovery rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power these rooms could be left with no power.

2. Receptacles in the OR's and recovery area need to be labeled with the circuit number and panelboard supplying them in accordance with NFPA-70, Section 517-19.

3. Critical receptacles are not provided in general care rooms in accordance with NFPA-70, Section 517-18.

4. The mechanical room accessed from the stairwell off of the OR corridor had an unmarked electrical panel that did not have a panel schedule and did not meet the requirements of NFPA-70, Section 110-22. This same mechanical room had seven isolation panels that did not have proper working clearance in accordance with NFPA-70, Section 110-26.

Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Normal power receptacles were not provided in the c-section rooms, and the nursery as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power these rooms could be left with no power.

2. Receptacles in the c-section room and nursery area need to be labeled with the circuit number and panelboard supplying them in accordance with NFPA-70, Section 517-19.

3. Critical receptacles are not provided in general care rooms in accordance with NFPA-70, Section 517-18.

4. The metal piping systems, (med gas and gas), are not bonded as required by NFPA 70-250.104(c). This could create a shock hazard for all building occupants.

5. Several panel schedules such as EMB-2 and the essential equipment panel in the boiler room were missing, handwritten, or not current and did not meet the requirements of NFPA-70, Section 110-22.

Based on random observation during the survey walk-through with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, and based on staff interview of the same personnel and based on random document review of monthly testing, the surveyor finds that all elevators within the facility do not conform with firefighters' recall requirements of ANSI/ASME A17.1/A17.3.

Failure to test and maintain elevator functions in accordance with ANSI/ASME A17.1/A17.3 could result in failure in a fire emergency. Failure to install and maintain emergency elevator functions in accordance with ANSI/ASME A17.1/A17.3 will result in loss of use by the Fire Department during a fire emergency.

Findings include:

East Building - Elevator # 7 serves four floors

A. The provider had no documentation that identifies annual testing and maintenance of Elevator # 7, including Phase I and Phase II fire fighters recall.

B. Elevator lobbies were observed to lack smoke detectors which comply with 19.5.3., 9.4.3.2., ANSI/ASME A17.3 1993 3.11.3. and ANSI/ASME A17.1 1993 211.3(b).

C. Elevator machine rooms were observed which lack smoke detectors required by ANSI/ASME A17.1 1993 211.3(b) and NFPA 72 1999 3-9.3.2.



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Based on random observation during the survey walk-through while accompanied by the Senior Director of Facilities Management, the surveyor found that 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. A single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation of each elevator is not provided as required by NFPA-70, Section 620-53.

2. The disconnect for the emergency lighting and controls for each elevator was not fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

3. The surveyor observed that the hydraulic elevator machine room was not equipped with sprinklers as required, and therefore was not a equipped with a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

Based on random observation during the survey walk-through with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, and based on staff interview of the same personnel and based on random document review of monthly testing, the surveyor finds that all elevators within the facility do not conform with firefighters' recall requirements of ANSI/ASME A17.1/A17.3.

Failure to test and maintain elevator functions in accordance with ANSI/ASME A17.1/A17.3 could result in failure in a fire emergency. Failure to install and maintain emergency elevator functions in accordance with ANSI/ASME A17.1/A17.3 will result in loss of use by the Fire Department during a fire emergency.

Findings include:

A. Center Building - Elevator # 1, and 2, serve four floors, Elevator 3, 4 & 5 serve six floors

The provider had no documentation that identifies monthly and annual testing and maintenance of all elevators including Phase I and Phase II fire fighters recall. The documentation available onsite (one page on red cardboard for multiple years) identifies compliance, monthly, with Phase I and Phase II requirements of ANSI/ASME A17.1/A17.3. However:

1. The documentation fails to identify specific testing for each elevator.

2. The documentation fails to identify the primary fire department designated floor of recall and the alternate floor.

3. The documentation identifies testing and compliance; however, most if not all elevator lobbies and elevator machine rooms lack smoke detection in accordance with ANSI/ASME A17.1/A17.3. Elevator recall functions on May 23, 3013 could not be tested with the surveyors present due to the lack of complying smoke detectors.

B. Elevator lobbies were observed to lack smoke detectors which comply with 19.5.3., 9.4.3.2., ANSI/ASME A17.3 1993 3.11.3. and ANSI/ASME A17.1 1993 211.3(b).

Note: elevator lobbies occur on both sides of some elevators on some floors. All lobbies lack smoke detection.

C. Elevator machine rooms were observed which lack smoke detectors required by ANSI/ASME A17.1 1993 211.3(b) and NFPA 72 1999 3-9.3.2.

D. The 6th Floor Elevator Machine Room is used for storage. The room lacks sprinkler protection and therefore does not comply with ANSI/ASME A17.1/A17.3 with storage in the machine room.


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B. Based on random observation during the survey walk-through while accompanied by the Senior Director of Facilities Management, the surveyor found that 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. A single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation of each elevator is not provided as required by NFPA-70, Section 620-53.

2. The disconnect for the emergency lighting and controls for each elevator was not fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

Based on random observation during the survey walk-through with the Senior Director of Facilities Management and/or the Director of Facilities Management, on May 21 and May 22, 2013, and based on staff interview of the same personnel and based on random document review of monthly testing, the surveyor finds that all elevators within the facility do not conform with firefighters' recall requirements of ANSI/ASME A17.1/A17.3.

Failure to test and maintain elevator functions in accordance with ANSI/ASME A17.1/A17.3 could result in failure in a fire emergency. Failure to install and maintain emergency elevator functions in accordance with ANSI/ASME A17.1/A17.3 will result in loss of use by the Fire Department during a fire emergency.

Findings include:

North Building - Elevator # 6 serves five floors

A. The provider had no documentation that identifies monthly and annual testing and maintenance of Elevator # 6, including Phase I and Phase II fire fighters recall.

B. Elevator lobbies were observed to lack smoke detectors which comply with 19.5.3., 9.4.3.2., ANSI/ASME A17.3 1993 3.11.3. and ANSI/ASME A17.1 1993 211.3(b).

C. Elevator machine rooms were observed which lack smoke detectors required by ANSI/ASME A17.1 1993 211.3(b) and NFPA 72 1999 3-9.3.2.


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Based on random observation during the survey walk-through while accompanied by the Senior Director of Facilities Management, the surveyor found that 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. A single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation of each elevator was not provided as required by NFPA-70, Section 620-53.

2. The disconnect for the emergency lighting and controls for each elevator was not fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

3. The surveyor observed that the elevator machine room was equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.