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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.

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. Corrected 03/12/14.
2. Corrected 03/12/14.
3. Corrected 4/17/14

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.

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.

Update 03/12/14: Designated hazardous rooms, boundary and sizes of suites are not identified on the updated Life Safety drawings.

2. Corrected 03/12/14
3. Corrected 03/12/14
4. Corrected 03/12/14

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. 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).

Note: 4/17/14 equipment is installed pending final city acceptance and certification package of completion for IDPH project 10025.

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 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. Corrected 4/17/14

2. a. Corrected 03/12/14
b. Corrected 03/12/14

3. Corrected 03/12/14
4. Corrected 03/12/14
5. Corrected 03/12/14

B. 1.Corrected 03/12/14
2. Corrected 03/12/14
3. Corrected 03/12/14

C. Corrected 03/12/14





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. Corrected 4/17/14
2. Corrected 4/17/14
3. Deleted 03/13/14.

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. Corrected 4/17/14

5. Corrected 4/17/14

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. Corrected 4/17/14
B. Corrected 4/17/14
C. Corrected 4/17/14



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. Corrected 4/17/14

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. Corrected 4/17/14

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.