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Based on record review and observation it was determined that building construction type and height did not meet the minimum construction. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19,3,5,1,

On 01/28/2014 at 10:22am while touring with staff M it was determined that:

1) The building minimum construction a four story building with basement and roof penthouse was noted at II(111) without complete fire sprinkler coverage which did not meet minimum construction requirements.

Based on observation corridors were not separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls properly extend above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms and activity spaces may be open to corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered. 19.3.6.1, 19.3.6.5.

On 01/27/2014 at 10:55am while touring the facility with staff M it was determined that:

1) 4th Floor Electrical Room was noted with four holes in corridor wall above the ceiling.

Based on observation and staff interviews it was determined the facility failed to ensure that doors opening onto the corridor close properly.


The findings include:


On 01/30/14 between 8:00 AM and 4:30 PM, observation revealed that a rated door was being held open by an unapproved device. Also, the soiled linen room failed to close and latch properly.

These findings were confirmed by Staff M at the time of discovery.

It was determined that stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors were not enclosed with construction having a fire resistance rating of at least one hour fire rating 8.2.5.6, 19.3.1.1.

On 01/27/2014 at 10:22 am while touring the facility with staff M it was observed and determined that:

1) Penthouse Mechanical Room in the Public Elevator Equipment Room there were beam cable penetrations, a three inch conduit penetration, and two insulated pipe were not sealed properly.

2) Penthouse in Elevator Equipment Room the two fire dampers were noted with activated thermal links and damper was propped open with metal device.

3) 4th Floor Stair C-NW was not labeled above the ceiling to indicate fire rating.

4) 3rd Floor Staff Lounge restroom above ceiling several unprotected floor penetrations.

5) 1st Floor Kitchen Pantry was noted with several unprotected vertical openings at waste and domestic piping.

Based on record review and observation it was determined that smoke barriers were not constructed to provide at lease a one hour fire resistance rating and constructed in accordance with 8.3 of NFPA 101.

On 01/27/2014 at 10:55 am while touring the facility with staff M it was determined based on record review and observation that:

1) 4th Floor PIMCU in corridor at double door above the ceiling in the smoke barrier was noted with unsealed openings and inadequate sealed penetrations.

2) 4th Floor at Elevator 44 and 45 was noted with unprotected opening in shaft and corner which did not maintain fire protection rating.

3) 4th Floor at two hour fire rated barrier which is in corner with windows on corner within 15 feet were not protected to provide a two hour fire rating.

4) 4th Floor and typical throughout building smoke barriers and fire barriers were not labeled above the ceiling to indicate the fire rating and statement to protect openings and penetrations.

5) 4th Floor C-NE Stair was noted with stair enclosure not being labeled above the ceiling.

6) 4th Floor the smoke barrier doors in corridor at room C423 was noted with excessive gap in door.

7) 4th Floor double door at room C423 was noted with holes above the ceiling in smoke barrier.

8) 3rd Floor Room at elevator 42 on plans was indicated as two hour barrier but only provided one hour fire rating.

9) 3rd Floor smoke barrier at Central Stair was noted with unsealed penetrations above the ceiling assembly.

10) 3rd Floor Housekeeping Room was noted with holes in ceiling and missing air handling register.

11) 3rd Floor near room C 335 in corridor the fire barrier above the ceiling was noted with PVC penetrations which were not sealed properly.

12) 3rd Floor the two hour fire barrier in corner was noted with unprotected openings (windows) within 15 feet (typical) 334 holes above the ceiling two hour barrier was not constructed to be two hour fire rated.

13) 3rd Floor Staff Lounge two hour fire barrier was not constructed properly to maintain fire rating.

14) 1st Floor C44 and 45 elevator lobby was not provided with smoke barrier doors for elevator lobby.

Based on observation and staff interviews it was determined the facility failed to ensure that all smoke barrier doors close fully to resist the passage of smoke.


The findings include:


On 01/27/14 between 1:00 PM and 4:30 PM through 01/28/14 between 8:00 AM and 12:00 PM, observation revealed the following:

1. The 4th floor smoke barrier door 014SD08 failed to close fully to resist the passage of smoke.

These findings were confirmed by Staff M at the time of discovery.

Based on record review and observation it was determined that the fire rated enclosure of hazard area was not enclosed in accordance with NFPA 101 and NFPA 80.

On 01/27/2014 at 3:30pm while touring the facility with staff M it was determined during record review and observation that:

1) 4th Floor CHOPS Soiled Utility Room walls were not sealed to maintain fire rating and gypsum joints were not taped and bedded.

2) 3rd Floor storage room, pantry, clean linen, locker room, and soiled utility rooms were not provided with walls sealed above the ceiling of at least one hour fire protection rating with self closing doors.

Based on observation and staff interviews it was determined that the facility failed to ensure that exit access is accessible.


The findings include:


On 01/27/14 between 1:00 PM and 4:30 PM, observation revealed that a copper pipe drain was draining directly into the egress corridor LL.

These findings were confirmed by Staff M at the time of discovery.

Based on observations, review of records, and interview with staff it was determined that emergency lighting provided was not installed, tested, or maintained in accordance with NFPA 101.

On 01/27/2014 at 03:50pm during interview with staff M, review of records, and touring the facility it was noted that emergency lighting failed to meet the code in the following locations:

1) 4th Floor Endoscopy Room the emergency lighting was not operational.

2) 3rd Floor Medication Room was not provided with emergency lighting.

Based on a review of records and staff interviews it was determined the facility failed to provide proof of fire drills to comply with the requirements of NFPA 101.


The findings include:


On 01/27/14 between 1:00 PM and 4:30 PM through 01/28/14 between 8:00 AM and 12:00 PM, a review of records revealed that one fire drill, per quarter, per year has not being conducted at the following locations:

1. The Hospice Building
2. The CAS Building
3. The Fertility Building

These findings were confirmed by Staff M at the time of discovery.

Based on observation and record review it was determined that the building fire alarm system and components were not installed, serviced, or maintained in accordance with NFPA 72.

On 01/27/2014 at 2:54pm while touring the facility with staff M it was determined from record review and observation that:

1) 4th Floor Building Automation Room was not provided with fire detection device interconnected to fire alarm system.

2) Basement Fire Alarm Control Panel was noted with panel indicating trouble, panel silence, and supervisory trouble.

3) Basement and throughout building Fire Alarm Control Panels were noted with past due battery replacement or certification and the batteries were not dated.

Based on observation and staff interviews it was determined the facility failed to ensure that the fire alarm system is maintained in accordance with NFPA 72.


The findings include:


On 01/27/14 between 1:00 PM and 4:30 PM through 01/28/14 between 8:00 AM and 12:00 PM, observation revealed that a trouble signal was indicated on the fire alarm panel.

These findings were confirmed by Staff M at the time of discovery and it was reported that the facility is currently in the process of having the system inspected, tested, and repaired.

Based on observation and record review it was determined that the building water based fire sprinkler system was not installed, maintained, and serviced in accordance with NFPA 13 and NFPA 25.

On 01/27/2014 at 03:05 pm while touring the facility with staff M it was determined by record review and observation that:

1) Penthouse Mechanical Room at door to C Central Stair fire hose valve box was noted with damaged or missing valve nut on hose valve assembly and handle was not attached to valve assembly.

2) 4th Floor in IT Room, mechanical room, and restrooms were not provided with fire sprinkler system.

3) 4th Floor (typical throughout) above the ceilings wiring and cables were noted being supported by the fire sprinkler piping which is not approved.

4) 4th Floor CHOPS Family Waiting Room restroom was not provided with fire sprinkler coverage.

5) 3rd Floor was not provided with fire sprinkler coverage.

6) 1st Floor was not provided with complete fire sprinkler coverage.

7) Basement at elevator fire sprinkler hanger was not installed properly.

8) Basement across from Pharmacy Fluid Room at north stair was not with sprinkler and water pipe above critical electrical panel in dedicated space of the electrical system.

9) Basement Main Switch Gear Room fire sprinkler piping in dedicated space of electrical equipment.

Based on record review, interview, and observatin it was determined that the building portable fire extinguishers were not installed, maintained, and service in accordance with NFPA 10.

On 01/28/2014 at 12:01pm while review of records and tour of the building it was determined that:

1) 1st Floor Mechanical Room portable fire extinguisher was located in unapproved location.

Based on observation, record review, and staff interview it was determined that building mechanical system failed to comply with codes.

On 12/12/2013 - 12/13/2013 while touring with staff M it was determined that the following items failed to comply with minimum requirements of the code:

1) 4th Floor (and typical throughout building) the return air arrangement was through the exit corridor in occupied space which is prohibited by code.

2) 4th Floor (and typical throughout building) the return air duct is noted with excessive lint build up and in need of cleaning.

3) 3rd Floor Mechanical Room the corridor was noted with an unapproved use of return air grill and use of corridor as return air plenum.

4) 3rd Floor Mechanical Room excessive lint was noted in return air duct.

5) 1st Floor the return air grill in corridor was constructed of unapproved combustible material. (wood grill).

Based on record review and observation it was determined that the cooking facilities was not protected in accordance with NFPA 101, NFPA 96, and NFPA 17A.

On 01/28/2014 at 10:11am while touring the facility with staff M it was determined based on record review and observation that:

1) 1st Floor Kitchen hood nozzles were not secured in place for deep fryer.

2) 1st Floor Kitchen nozzle over range obstructed by shelf.

3) 1st Floor Kitchen filters were not in correct position to remove grease laden vapor.

Based on observation portable space heating devices was found in health care occupancy. 19.7.8

On 01/28/2014 at 11:46am while touring with staff M it was observed that:

1) 1st Floor in Pastoral Care Room an electrical space heating device was found and was connected for use.

Based on record review and observation it was determined that medical gas storage and administration areas were not protected, used, and maintained in accordance with NFPA 99, Standard for Health Care Facilities.

On 01/27/2014 at 11:15 am while touring the facility with staff M it was determined by record review and observation that:

1) 4th Floor C420 was noted with oxygen stored or used in room and corridor door to room was not provided with approved oxygen use sign-no smoking.

2) 4th Floor Endoscopy Room corridor door was not provided with oxygen use sign and oxygen in room.

3) 4th Floor Corridor at alcove near room C 408 was noted with unapproved storage of oxygen stored in the corridor.

4) 3rd Floor Clean Linen Room oxygen stored without door sign.

Based on observation and staff interviews it was determined the facility failed to ensure that the generator is being properly serviced and maintained.


The findings include:


On 01/27/14 between 1:00 PM and 4:30 PM, observation revealed that diesel fuel was leaking from the supply lines to the day tanks for generators 1,2,and 3 in the central energy plant.

These findings were confirmed by Staff M at the time of discovery.

Based on record review and observation it was determined that the buildings electrical system did not meet the requirements of NFPA 70 or was not maintained in accordance with electrical equipment specifications.

On 01/27/2014 at 10:20 am while touring with staff M it was determined that the following deficiencies were noted failing to meet code requirements:

1) Penthouse Mechanical Room the flammable liquid cabinet was not provided with electrical static ground wire from cabinet to grounding connection.

2) Roof with mechanical equipment surface mounted was not provided with 120v electrical receptacle for repairs in two locations not to exceed one hundred feet from any equipment.

3) 4th Floor at double doors to PIMCU above the ceiling was noted with low voltage box not secured or provided with closed cover.

4) 4th Floor computer in patient rooms were not provided with indication that electrical safety check was conducted.

5) 4th Floor PIMCU #4 Telemetry antenna was not provided with electrical T BAR in ceiling assembly and was typical throughout the building.

6) 4th Floor NICU soiled utility hall was noted with IV poles obstruction of means of egress clear width.

7) 4th Floor and (typical throughout building) electrical and mechanical rooms were not provided with corridor door signs indicating room number or usage.

8) 4th Floor OR C410 the patient monitor electrical certification was not provided with safety check on CHOP 14

9) 4th Floor CHOP area IT equipment was not provided with approved height above floor and not protected from damage.

10) 3rd Floor (throughout) above the ceiling was noted with wiring and conduit laying on ceiling assembly and not supported properly and some items were on fire sprinkler systems.

11) 3rd Floor patient room were noted with loose or not secured duplex electrical receptacles.

12) 3rd Floor Electrical Room at elevator 46 was noted with circuit not complete.

13) 3rd Floor Office across from room plug strip was not mounted above the floor and cord safety routed.

14) 3rd Floor Mechanical Room was noted with abandon wiring above the ceiling in several locations.

15) 1st Floor Kitchen Pantry Coolers were noted with unapproved electrical junction boxes (not approved for wet or damp locations).