HospitalInspections.org

A) The Hospital is five stories in height and is mostly Type I (332) Construction. Portions of the Hospital have been found to be unprotected steel, Type II (000) Construction and they do not comply with 19.1.6.2:

1) The Main Hospital Entrance (with a revolving door) is a space with a 20' high ceiling. The Entrance Foyer in front of this space and the vehicular drop-off canopy are all supported by structural steel the runs back into the Hospital.

a) The construction type of the Canopy and Foyer is Type II (000) Construction.

04/17/10: The corrective action proposed for the above was not completed in accordance with the last submitted PoC. The provider failed to submit a revised PoC for the above items.

b) Deleted 4/15/10.

c) (Modified 11/18/09): A two hour fire separation between the one story addition that includes the Entrance Lobby and the Emergency Department from the multi-story hospital is not identified on the Life Safety Code Master Plan. The one story addition that incudes Type II (000) Construction is sprinklered and is permitted if the two hour separation can be confirmed.

04/17/10: The two hour separation between the multiple story portion of the building and the one story addition (and the two hour separation between differing construction types) exists in places. However, the two hour fire barrier is not accurately shown on the Life Safety Code Master Plan as currently revised. The provider has not taken steps to confirm the location and/or confirm that accuracy of the master plan. The two hour fire walls shown on the master plan at the public bathrooms do not exist.

04/17/10: Either item A 1) a) or A 1) c) must be corrected in order to clear this tag.

2) Corrected 04/16/10

3) Corrected 04/16/10

4) Corrected 11/17/09

Note 04/16/10: all citations under this tag have been corrected. However, the provider's Life Safety Code Master Plans continue to show inaccurate information. K018 will be cleared when K048 is corrected.

A) From random observation, the surveyors find that corridor doors have deficiencies and do not comply with 19.3.6.3 and/or other sections of Chapter 19.

1) Corrected 11/18/09
2) Corrected 11/18/09
3) Corrected 11/18/09
4) Corrected 11/18/09

5) Corrected 04/16/10

6) Corrected 11/17/09
7) Corrected 11/17/09
8) Corrected 11/17/09

9) 5 East - Corrected 04/16/10 no response required - Only one suite is identified on the plans; it is separated from the west portion of the unit by a two hour fire barrier. There is an additional smoke barrier immediately to the west - see K024.

10) Corrected 11/17/09

11) The 4th Floor ICU Unit is not a suite and cannot be a suite - Corrected 04/16/10 - See K048

12) Corrected 04/16/10

13) Deleted 04/16/10

14) Corrected 11/17/09

A) From random observation the surveyors find that vertical openings are not protected or enclosed in accordance with 8.2.5 of NFPA 101:

1) Corrected 11/18/09
a) Corrected 11/18/09
b) Corrected 11/18/09

c) The Laundry Room is sprinklered as is the lower portion of the former stair. The upper portion of the stair, within the same space, is not sprinklered and a portion of the ceiling is missing.

d) Deleted 04/16/10
2) Corrected 04/16/10
3) Corrected 04/16/10
3a) Corrected 04/16/10
4) Corrected 11/17/09
5) Corrected 04/16/10

6) 2nd Floor Closet with pair of doors opposite from Elevators 2 & 3: The closet is open to an adjacent shaft and is not protected as part of the shaft.

11/17/09 - 04/16/10: one conduit penetration into the above shaft is not sealed for two hour construction.

7) Corrected 04/16/10
8) Corrected 11/18/09

A) Based upon random observation, the surveyors find that fire doors and smoke doors throughout the building are held open or have automatic opening/hold open functions. While some of these doors close upon activation of the fire alarm system, none of the doors close upon activation of the sprinkler system in accordance with 7.2.1.8.2, 7.2.1.9.2 and 18.2.2.2.6.

1) The provider lacks documentation that identifies each location, door by door, and indicates that the door is tested annually from activation of the fire alarm system and from the sprinkler system, in accordance with NFPA 72.

The above item includes all fire shutters.

2) a) b): Corrected 04/16/10

2) c) (Modified 11/17/09): Pair of auto-open/auto hold open doors to the Ambulance Bay. These doors also do not close and latch upon activation of the fire alarm and sprinkler system. 04/16/10: the doors failed to latch.

3) Corrected 11/17/09

4) (New 04/16/10) There is a pair of designated 5th Floor smoke doors that are just east of Stair # 2: These doors have automatic opening functions that are not disabled automatically upon activation of the fire alarm system. (see also Item 1 above)

A) (Modified 04/16/10): The provider still lacks accurate information that demonstrates compliance with 19.3.7.1. The life safety plans available still are not accurate. (see K048)

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

Modified 04/16/10: The provider lacks accurate information that identifies the boundaries of each smoke compartment, and the fire ratings for barriers that separate smoke compartments. See K048.

1) Modified 04/16/10: see K025

a) Deleted 4/16/10

b) Deleted 4/16/10 - see K048

c) See K048

d) Corrected 4/16/10


2) Deleted 04/16/10

B) Deleted - not used

C) (New 11/18/09): The one story 1995 addition that includes the 1st Floor Main Entrance Lobby and the 1st Floor Emergency Department constitutes new construction that required a complying smoke barrier. A smoke barrier that includes the above space is not identified on the Life Safety Code Master Plan in accordance with 18.3.7.3.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

D) (New 11/18/09): The 2004 Project that includes the 1st Floor Cardiac Cath Lab Suite constitutes new construction that required a complying smoke barrier. A smoke barrier that includes the above space is not identified on the Life Safety Code Master Plan in accordance with 18.3.7.3.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

E) (New 11/18/09): The 1st Floor West Wing has a continuous barrier that includes smoke dampers at duct penetration. Barring evidence to indicate otherwise, the surveyor finds that this barrier is an existing smoke barrier that defines a smoke compartment in the West Wing. This smoke barrier may not be diminished (4.6.7). The smoke barrier is not identified on the Life Safety Code Master Plan in accordance with 18.3.7.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

F) Corrected 04/16/10
1) Corrected 04/16/10
2) Deleted 04/16/10
G) Corrected 04/16/10 .
H) Deleted 04/16/10

A) Based upon the limited information available and based upon random observation, the surveyors find that smoke barriers are not constructed and maintained to comply with 19.3.7.3 (see also K024, K027 and K104. The surveyors also note that the building is only partially sprinklered and does not comply with any exceptions for sprinkler protection except for locations entirely within 5 East and 4 East)

1) Deleted 11/17/09
2) Corrected 11/17/09
3) Corrected 11/17/09
4) Corrected 11/17/09
5) Corrected 11/17/09
6) Corrected 11/18/09 - see K104.

7) 1 West: The designated smoke barrier (Old PT Area) has a sliding glass pass through window that does not comply with 19.3.7.5. A smoke barrier is identified in the PoC. 04/16/10: The Life Safety Code Master Plans still do not clearly identify the location of a complying smoke barrier. The above item was not corrected in accordance with the last submitted PoC and based on multiple citations around that same issues the surveyor finds that the provider lacks a competent peer review to confirm what is shown on the Life Safety Plans.

The provider lacks accurate information to indicate that the referenced window is not located in a smoke barrier and in the boundary wall of a suite. The window does not comply with 19.2.2.2.6 and/or 19.3.6.5

04/16/10: 1 West is also identify as a suite. The pair of corridor doors at the suite boundary are designated suite doors and smoke doors. The doors do not latch automatically upon activation of the fire alarm system.

8) (New 4/16/10) Smoke barriers are not constructed as at least one half hour fire barriers that are smoke tight to the deck above in accordance 19.3.7: See also K24, K44, K048)

a) 5 East: The designated smoke barrier near the Nurse's Station (5327) has unsealed penetration(s) above the north pair of smoke doors above the ceiling.

b) 5 East: There is a designated smoke barrier south of the nurse's station. The is no wall above the pair of designated smoke doors, south of the nurse's station.

c) 5 East: The designated smoke barrier (west wall of the above nurse's station) has an unsealed penetration.

d) The designated smoke barrier for 4 East is deficient.

i) A portion of the smoke barrier is missing
above the ceiling in Room 4317
(Isolation Room).

ii) There is an unsealed penetration above
the pair of doors to the ICU.

e) 3 Center: The designated smoke barrier has sleeves (interior of sleeves) and penetrations that are note sealed for fire rated construction.

f) Te designated smoke barrier between the corridor and Room 3331 has a one inch gap at the top of the wall above the ceiling.

g) The current Life Safety Master Plans identify a smoke barrier at 2 South. The designated smoke barrier is deficient; the south wall of the Beauty Shop is missing above the ceiling.

If the smoke barrier remains on the Life Safety Master Plans, correction will be required. If a complying two hour fire smoke barrier is installed, as required by a Long Term Care Surveyor, at 2 North and the 2 South smoke barrier is deleted from the plans, correction at 2 South will not be required. The Life Safety Plans will need to be revised to show the revised smoke compartment sizes and the reviews locations of fire and smoke barriers.

h) See K024 and K025: There are smoke barriers on the 1st Floor that must be identified and then inspected to confirm compliance.

A) Based upon random observations the surveyor finds that hazardous areas are not separated and enclosed in accordance with 19.3.2.1.

1) Corrected 11/17/09
2) Corrected 11/17/09
3) Corrected 11/17/09
4) Corrected 11/17/09
5) Corrected 11/17/09
6) Corrected 11/17/09
7) Corrected 11/17/09
8) Corrected 11/18/09

9) (Modified 04/16/10): Lower Level Kitchen Storage Area: the door(s) to this space lack self closing hardware. The hold open device on this door lacks smoke detection on both sides of the door in accordance with 7.2.1.8.

10) Corrected 11/17/09
11) Corrected 11/17/09
12) Corrected 04/16/10






26665


(A) Based on random observation, the surveyor finds that the lower level as a mixed occupancy with business, storage, assembly and health care uses and numerous rooms containing storage that constitutes hazardous areas. These hazardous areas are not separated from other areas in accordance with NFPA 101 Section 8.4. Locations include but not limited to;

1) Corrected 04/16/10

2) Medical records storage room B. (multiple doors)

3) Corrected 04/16/10
4) Corrected 04/16/10
5) Corrected 04/16/10

A) Based upon random observation the surveyor finds that exits are not enclosed and maintained as protected path to a public way in accordance with Chapter 7 of NFPA 101.

1) (Modified 04/16/10) Center Stair Lower Level. This stair is identified by the provider as a convenience stair on all floor levels.

a) Deleted 04/16/10

b) The provider lacks adequate to-scale floor
plans.

04/16/10: Based upon information
received for the provider's architect, the
stair is a required exit from the Lower
Level

c) Deleted 04/16/10

d) (New 04/16/10): The PoC does not
clearly indicate how and when this stair
will either comply with 7.7.1 or 7.7.2.

The PoC states that it can comply with
certain items (that are actually part of
7.7.2). However the PoC does not
clearly identify compliance with 7.7.2
and/or how and when it will comply
with 7.7.2

2) Corrected 11/18/09

3) Corrected 11/17/09

4) Corrected 04/16/10

5) (Modified 04/16/10): The North Exit Stair discharges at the 1st Floor through a required exit passageway. This exit passageway is still not identified on any plans. The exit passageway has two bathrooms within the required exit enclosure.

04/16/10: The Master Plan has not been modified to identify "Existing Exit Passageways" on the plans, as indicated in the last submitted PoC. The provider should also note Section 7.1.3.2.1 e) - new exit passageways and not permitted to have duct penetrations and/or any other penetrations that do not specifically serve the exit. or)

Alternately; the PoC does not indicate how the stair discharge can comply with 7.7.2, without correction of the items below.

a) Corrected 04/16/10

b) A fire alarm penetration above the
ceiling at the west wall of this exit
passageway is not sealed

c) The two bathrooms are not
separated from the exit passageway by
walls that are two hour rated to the deck
above and by B Label doors.

6) The East Exit Stair discharges at the 1st Floor through a required exit passageway. This exit passageway is STILL not identified on any plans as an "Existing Exit Passageway.".

a) Corrected 04/16/10

b) Corrected 11/18/09

A) From random observation, the surveyor finds that exits and/or exit paths are locked or are obstructed and/or do not otherwise comply with Chapter 7 of NFPA 101.

1) Deleted 11/18/09

2) Deleted 4/16/10

3) 4 North/4 West: The 4th Floor Obstetrics Unit has two required exit stairs and one additional exit path out of the unit with two independent locking devices.

a) Corrected 11/18/09

b) The provider lacks documentation that
indicates that each of these locking
systems (those that remain active)
are tested annually and that they
release from activation of the fire alarm
system and from the sprinkler system.

The above item will be cleared from document
review during an onsite visit.

4) Corrected 04/16/10

5) Corrected 11/18/09

6) (New 4/16/10): 3rd Floor: An exit sign south of the locked down unit directs the exit path south and north. The path identified to the north is blocked by a locked door.

A) Based upon random observation the surveyor finds that designated fire barriers are not installed and maintained in accordance with Chapter 8 of NFPA 101 - 2000:

1) Corrected 04/16/10

2) Corrected 11/18/09

3) Modified 11/18/09: The provider indicated that the 2nd Floor SNF unit on 2 West is separated from the rest of the building by a two hour fire barrier (not necessarily required). The surveyor notes that 2 West is separated from the rest of the floor by a smoke barrier (rating unknown).

a) Deleted 04/16/10

b) The Life Safety Code Master Plans will need to be revised to accurately show complying smoke and fire barriers for the 2nd Floor (based upon the PoC for the Hospital and the PoC for the SNF Unit). See also K025

c) (04/16/10 - Modified from above): The current Life Safety Master Plans identify a smoke barrier at 2 South. The designated smoke barrier is deficient; the south wall of the Beauty Shop is missing above the ceiling. See also K025

If the smoke barrier remains on the Life Safety Master Plans, correction will be required. If a complying two hour fire smoke barrier is installed, as required by a Long Term Care Surveyor, at 2 North and the 2 South smoke barrier is deleted from the plans, correction at 2 South will not be required. The Life Safety Plans will need to be revised to show the revised smoke compartment sizes and the reviews locations of fire and smoke barriers.

4) (Modified 04/16/10) The single door behind the 2nd Floor Center Nurse's Station, to the SNF activity room has a magnetic hold open device. The wall is a required two hour fire barrier and possibly a required smoke barrier.

The door hold open lacks local smoke detection in accordance with 7.2.1.8. This was not corrected in accordance with the last submitted PoC. A smoke detector has not been installed within five feet of the door.

A. (Modified 04/16/10 - based upon a revised set of Life Safety Code Master Plans): Although this facility has been cited on previous surveyors for the lack of on-site information regarding their building, the provider still lacks a comprehensive Life Safety Code Master Plan for each floor. The plans dated 10/26/09 are not accurate and lack a peer review to confirm that information identified on the plans

1. All exit access corridors are still not clearly identified!

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

2. The provider currently has multiple Exit Passageways that are still not specifically identified as "Exit Passageways" on the Life Safety Code Master Plans. Further, if these are "existing exit passageways" they are not identified as such to avoid more stringent requirements for new exit passageways under 7.1.3.2.1 e).

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

2. (Modified 04/16/10): Two hour fire barriers are clearly identified. In some cases the line designation for two hour barriers is combine with the line used for smoke barriers. It is assumed (but needs to be clarified) that such use of lines designates a two hour fire/smoke barrier. The line used to designate one hour barriers does not define anything. NFPA 101, based upon previous requirements for health care, has five one hour barriers with differing requirements. The plans and plan key do not differentiate between.

a) Existing one hour corridor walls (to the deck above) with 20 min. (or equiv) corridor doors with positive latching hardware.

b) One hour smoke barriers to the deck above with 20 min self closing doors (wire glass in all vision panels).

c) One hour enclosure of hazardous areas (with 3/4 hour fire rated doors openings)

d) One hour exit enclosures with B Label, one hour fire rated doors)

e) One hour shaft enclosures with opening protectives

f) Additional possible wall types in existing buildings that are not clearly identified if used or where applicable:

i) Corridor walls to the deck above that are
only 1/2 hour (constructed prior to 1985)
and that otherwise comply with 19.3.6.2
through 19.3.6.5.

ii) Existing smoke barriers that are 1/2 hour
rated (constructed before 1985) and that
otherwise comply with all of 19.3.7.

g) Hazardous areas are not all clearly identified.

3. Smoke barriers are identified. The fire ratings (1/2 hour, 1 hour or 2 hour) for each designated smoke barrier are not identified. Further, smoke barriers are indicated in the PoC but are not identified on the Life Safety Plans. (see K024)

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

4. Corrected 04/16/10

5. Corrected 11/18/09

6. Deleted 11/18/09

7. Deleted 11/18/09

8. (Modified 04/16/10): Suites are identified but in some cases cannot be confirmed.

a) The 4th Floor ICU Suite (4 East) is not a suite and cannot comply as a suite. This suite is misidentified.

b) The boundaries and compliance with 19.3.6.5 cannot be confirmed by the suite identified at 1 West.

9) 4/16/10: Scalable Life Safety plans were not available on site. The plans provided lack a bar scale and were not reproduced to any recognizable scale. The minimum acceptable scale will be limited to 1/16" = 1'-0".

A) Based upon random observation and document review of fire drill records for 12 months, the surveyor finds that fire drills are always conducted around 8:00 - 8:30AM, 1:00 - 1:45PM, 6:30PM. and 5:10 - 5:40AM. The surveyor notes the facility has 12 hour shifts and 8 hour shifts and that shift changes occur at varying times. Fire drills are not conducted at varying times in accordance with 19.7.1.2.

PoC to be avaluated on future surveys

A) Sprinkler systems are not installed and maintained in accordance with NFPA 101, NFPA 13, and NFPA 25:

1) The Lower Level Cafeteria and Dining Room is part of a mixed use (Assembly, Business, Storage and Health Care) occupancy. This area was recently renovated but was not provided with sprinkler protection in accordance with 19.1.1.4.5.

4/16/10: No PoC was provided for the above item under this tag; PoC is incomplete.

2) The Lower Level Dry-pipe sprinkler system room for the 1st Floor MRI is located in a space that is sprinklered. However, the space is open to the adjacent ceiling cavity(s) and those ceiling cavities are not sprinklered.

3) Corrected 04/16/10

4) 4 East is a fully sprinklered fire compartment or smoke compartment. The wardrobe units in each patient room lack sprinkler protection.

5) Corrected 11/18/09

6) The sprinkler protection in the 5 East Sterile Core is obstructed in a few locations by storage higher than 18" below the sprinkler heads.

7) Corrected 11/18/09

8) 11/18/09: The sprinkler protection in the 1st Floor Medical Library is obstructed by wood shelf units. (spacing is incomplete or one head is still missing)

9) (New 11/17/09): There is a Communication Closet with a pair of doors near Room 4317 - the space is not sprinklered.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.




26665


A) Deleted 04/16/10
B) Corrected 11/18/09

A) Based upon random observation from testing and the lack of documentation, the surveyor finds that some sprinkler control valves are not supervised electronically and many are not tested at least annually in accordance with NFPA 25.

1) The annual sprinkler system documentation of testing (and/or any other testing performed) does not provide an list item-by-item list of each tamper switch tested along with a pass/fail analysis. A list of the total number of devices tested vs the total number existing was also not available. The forms are not filled out completely and the documentation is incomplete. The surveyor could not determine what has been tested.

2) Corrected 11/18/09

3) Corrected 11/18/09

A) From document for the past twelve months and from personnel interview, the surveyors find that the building sprinkler systems are not tested serviced and maintained in accordance with NFPA 25.

1) From interview the surveyor find that some sort of flow testing is conducted. However, the surveyors did not find documentation that indicates that every flow switch is tested quarterly and the documentation available does not identify the location of each flow switch, the date of testing and the time from water flow to activation of the fire alarm system. Nor is it clear from the documentation whether any devices failed. On July 22, 2009 two of three devices failed to activate the fire alarm system.

2) Modified 11/18/09: The documentation (documentation of 6/30/09) of annual testing, service and maintenance of the sprinkler system is incomplete:

a) The anti-freeze system for the
Ambulance Bay indicates that it tests
only to 16 degrees F, in a region that
regularly experiences winter with
subzero temperatures.

b) There is an anti-freeze system in the
foyer in front of the Main Entrance
Lobby. It is accessed from a
panel in a column at one side of the
entrance. The tag on this system
indicates that it was last serviced in
2004. No other information was
available.

c) The 1st Floor MRI unit or area is
protected by a pre-action
dry-pipe sprinkler system. The
documentation for this system is
incomplete. The forms are not
completely filled out for this system.
There is no indication that the dry
pipe valve is internally inspected
and exercised annually. The
documentation does not identify the
yearly partial pressure drop test
and the three year full pressure
drop test, including the time from
pressure loss to fire alarm activation.

d) No documentation indicates that all
sprinkler control valves are exercised to
full range of motion and then lubricated.

e) Documentation for 5 year testing of
gauges indicate yes and no. This
documentation requires more
explanation.

3) The fire pump is powered by a diesel engine. The documentation for recent test of this diesel engine was not signed. The documentation indicated that there were three items that were unsatisfactory but did not indicate what they were.

4) The provider indicated that a weekly churn test is performed on the fire pump but failed to provide documentation that indicates that a fire pump churn tested is conducted weekly for at least one half hour, in accordance with NFPA 20.

A) Based upon random observation, the surveyor finds that HVAC systems, fire dampers, smoke dampers, etc. are not installed in accordance with NFPA 90A:

1) Corrected 11/18/09

2) Corrected 11/18/09

3) Corrected 04/16/10




26665


A) Based on random observation, the surveyor found access panels in ductwork which contained fire protection devices (fire dampers, smoke dampers, duct detectors, etc.) that were not identified with letters 1/2" high identifying the type of fire protection device with-in as required by NFPA 90A 1999 2-3.4.2. Locations include but are not limited to;

1) Corrected 11/18/09
2) Corrected 11/18/09.
3) Corrected 04/16/10

B) Based on observation, the surveyor found locations where air intakes were installed less than 3' above the roof surface, air filters not sealed to prevent bypass and filter banks installed with no device to monitor pressure drop across the filters as required by NFPA 90A and ASHRAE Chapter 7.

4/16/10: the PoC does not appear to address the filter deficiencies and monitoring deficiencies cites above.

1) Corrected 11/18/09
2) Corrected 11/18/09
3) Corrected 11/18/09
4) Corrected 11/18/09
5) Corrected 04/16/10

6) The second floor mechanical room AHU's air intakes were observed to be less than 3' above the roof surface.

04/16/10: The above item was not corrected in accordance with the last submitted PoC. A 01/08/10 final correction date was identified in the PoC.

A) Based on random observation, the surveyor found components of the linen and trash chutes which does not comply with NFPA 82 requirements for self -closing and latching.

1) The first floor trash chute door in the corridor does not latch as required by 3-2.4.2.

2) Corrected 04/16/10

3) The lower level trash collection room chute door does not latch as required by 3-2.4.2.

4) The lower level linen collection room chute door does not latch as required by 3-2.4.2.

5) The lower level trash collection room chute door was tied open with a wire which prohibits self-closing.

6) The lower level linen collection room chute door was tied open with a wire which prohibits self-closing.

A) From observation, the surveyors find that oxygen storage tanks are stored (place in rack and not in locations for immediate use) in rooms with combustibles and do not comply with NFPA 99. In rooms with sprinkler protection oxygen is stored closer than five feet to combustible. In rooms without sprinkler protection oxygen is stored closer than 20'-0" to combustibles. Locations include but are not limited to:

1) 4th Floor ICU Storage Room - not corrected 11/18/09 4/16/10 - not shown to surveyor.

2) Corrected 11/18/09

3) Corrected 04/16/10

A) The surveyors find that the facility has an outside bulk oxygen storage system that does not comply with NFPA 99 and NFPA 50:

1) Corrected 11/18/09

2) The nearby recycling shed and the combustibles within are not at least 25 feet from the oxygen tanks.

04/16/10 - revise the correction date for the above item.

B) From random observation the surveyors find that medical gas systems are not installed and maintained in accordance with NFPA 99 - 1999.

1) Corrected 11/18/09

2) Corrected 11/18/09

3) All floors with medical gas vacuum outlets in patient rooms or recovery spaces. Medical gas shut off valves were not found. The provider was not able identify the location of the vacuum riser shut off valves for each floor. Locations include but are not limited to:

a) 5th Floor Stage II Recovery spaces.

b) 4 East Bronchoscopy Room and 4 East
patient rooms.

c) Patient rooms of 3 North

4/16/10: The above items were not corrected in accordance with the last submitted PoC. A revised PoC either indicating what corrections are required or indicating why correction is not required, was not submitted prior to the correction date indicated in the PoC. The year of installation for each existing system is required to confirm that correction is not required.

4) Corrected 11/18/09

5) 5th Floor Surgical Unit.

a) Corrected 4/16/10

b) Pre-op and the Post operative
Recovery Room have medical air,
oxygen and vacuum medical gas vacuum
systems. The vacuum system lacks area
shut off valves.

c) O R # 7 and O R # 8 have have medical
gas vacuum system but lack room, area
or floor shut off valves.

d) Corrected 11/18/09

4/16/10: The above items were not corrected in accordance with the last submitted PoC. A revised PoC either indicating what corrections are required or indicating why correction is not required, was not submitted prior to the correction date indicated in the PoC. The year of installation for each existing system is required to confirm that correction is not required.

A) Based upon the limited information available and based upon random observation, the surveyors find that smoke barriers have duct penetrations that lack smoke dampers or combination fire smoke dampers in compliance with 19.3.7.3. The surveyors also note that the building is only partially sprinklered and does not comply with exception # 2 for sprinkler protection except for locations entirely within 5 East and 4 East)

1) Deleted 11/18/09

2) Deleted 11/18/09

3) Corrected 04/16/10

4) The designated two hour barrier at the entrance to 2 East has one or more duct penetrations with no combination fire/smoke dampers. This barrier is not identified on the Life Safety Code Plan as a two hour fire barrier, as a smoke barrier or both. One or both may be required.

5) Corrected 04/16/10

The surveyors find that above citations are examples only and not a comprehensive list. The surveyors also find that provider lacks a complete list of all fire dampers and smoke dampers with the locations identified.

04/16/10: The surveyor finds that some locations have smoke dampers and/or combination fire/smoke dampers with coil-op designs and a motor on top of the duct, while other dampers are pivoting type dampers with a pivot or axle running vertically through duct and a motor on top. The surveyor does not find documentation that shows that these fire dampers are tested and maintained in accordance with NFPA 90A.

Also the surveyor finds that the damper motor assembly is recess into the fire wall on top of the duct. This creates a void in the fire barrier of smoke damper in the barrier above the duct. The surveyor finds no information on site to show how this condition is smoke tight and/or fire rated.

A) The surveyors find that the provider has emergency power systems that are not installed, tested and maintained in accordance with NFPA 70, NFPA 99 and NFPA 110. The provider has three diesel fueled emergency generators in one room.

1. Existing generator # 1, according to the provider, is not longer functioning and has been disabled. One sign was observed on this generator indicating that it was out of service.

*No sign was provided at the generator
controls, tagging the generator as "out of
service"

04/16/10: the above item was not corrected in accordance with the last submitted PoC.

*No sign was provided at the emergency stop
for generator # 1, indicating that it was out of
service.

04/16/10: the above item was not corrected in accordance with the last submitted PoC.

*At two of two remote alarm panels for
generator # 1, signage was not provided,
indicating that it was out of service.

2. A new 750 KVA emergency generator was installed (roughly January of 2008). This project was not submitted to the Department for review and approval.

a. Corrected 04/16/10

b. The provider has documentation of an
initial four hour load bank test for the
new generator but lacks other
documentation of initial acceptance
testing, including but not limited to the
maximum time of activation for life
safety and critical branch systems.

c. A monitoring panel is installed in
the switchboard area for the new
generator; however an remote
monitoring panel has not been installed
in the Lower Level Engineering
workspace, in accordance with
NFPA 99.


The above citation will not be cleared until the project certifications have been submitted and the project (IDPH # 8893) has been inspected by the Department. The correction dates identified in the PoC do not indicate completion.

A) Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

1) The provider failed to implement and document adequate interim life safety measures for the conditions cited.

2) ISLM were not reviewed on 4/16/10

B) Corrected 04/16/10

A) Based upon random observation, the surveyors find that two of two emergency generators are not tested and maintained in accordance with NFPA 99 and NFPA 110.

1) The surveyors found no documentation that indicate that each generator is inspected visually at least once a week. The surveyors did find documentation of daily inspections but the provider lacked any information about what was required during these inspections. There is no evidence that the generators are inspected weekly in accordance with the referenced standards and/or the generator manufacturer's recommendations.

2) The monthly load testing documentation for each generator does not clearly identify which transfer switches were activated for each test. The documentation does not indicate which transfer switch was used to initiate the load test. And the total run time, under load, is not clearly identified.

A) From random observation, the surveyors find that electrical installations and materials do not comply with NFPA 70 - 1999:

1) Deleted 11/18/09

2) Corrected 04/16/10

3) Corrected 04/16/10

4) (New 04/16/10): 1st Floor North (Panels V & B) the circuit numbers on the panels do not match the panel schedule.





26665


A) Based on random observation, the surveyor observed wiring and panel directories throughout the facility which were not installed and maintained in accordance with NFPA 70 1999.

1) Breaker panels contained directories which were not current and legible as required by 384-13.

2) North wing - electric panel Z was observed to have circuit breakers removed without blanks installed as required by 373-4

3) Cables were observed throughout the facility which were not supported by the structure as required by 800-6.

A) Based upon random observation and document review that surveyors find that seven of seven elevators (all elevators except for two freight elevators) are not installed and/or tested in accordance with ANSI A17.3.

1) The provider lacks documentation demonstrating that every elevator is tested for automatic fireman's recall (floor and alternate floor) for every elevator, annually.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

2) (Modified 11/18/09): Elevator # 4 lacks automatic and manual recall in accordance with ANSI A17.3.

04/16/10: The above item was not corrected in accordance with the last submitted PoC. The PoC was not modified and resubmitted with a new correction date before the correction date identified in the last submitted PoC. The PoC for the above item msut providxe a detailed phasing schedule, with dates, that identifies how it will be brought into compliance or) it is to be disabled and walled off immeidately.

3) (New 11/18/07): Based upon direct observation the surveyor finds that Elevator 1, 2 and 3 lacks automatic recall to a designated alternate floor in accordance with ANSI A17.3. Activation of a 1st Floor Elevator Lobby smoke detect results in recall of the elevator to the 1st Floor with the doors opening to the floor or fire origin.

04/16/10: The above item was not corrected in accordance with the last submitted PoC. The PoC was not modified and resubmitted with a new correction date before the correction date identified in the last submitted PoC.

A) (Modified 04/16/10): The provider still lacks accurate information that demonstrates compliance with 19.3.7.1. The life safety plans available still are not accurate. (see K048)

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

Modified 04/16/10: The provider lacks accurate information that identifies the boundaries of each smoke compartment, and the fire ratings for barriers that separate smoke compartments. See K048.

1) Modified 04/16/10: see K025

a) Deleted 4/16/10

b) Deleted 4/16/10 - see K048

c) See K048

d) Corrected 4/16/10


2) Deleted 04/16/10

B) Deleted - not used

C) (New 11/18/09): The one story 1995 addition that includes the 1st Floor Main Entrance Lobby and the 1st Floor Emergency Department constitutes new construction that required a complying smoke barrier. A smoke barrier that includes the above space is not identified on the Life Safety Code Master Plan in accordance with 18.3.7.3.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

D) (New 11/18/09): The 2004 Project that includes the 1st Floor Cardiac Cath Lab Suite constitutes new construction that required a complying smoke barrier. A smoke barrier that includes the above space is not identified on the Life Safety Code Master Plan in accordance with 18.3.7.3.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

E) (New 11/18/09): The 1st Floor West Wing has a continuous barrier that includes smoke dampers at duct penetration. Barring evidence to indicate otherwise, the surveyor finds that this barrier is an existing smoke barrier that defines a smoke compartment in the West Wing. This smoke barrier may not be diminished (4.6.7). The smoke barrier is not identified on the Life Safety Code Master Plan in accordance with 18.3.7.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

F) Corrected 04/16/10
1) Corrected 04/16/10
2) Deleted 04/16/10
G) Corrected 04/16/10 .
H) Deleted 04/16/10

A) Based upon random observation the surveyor finds that designated fire barriers are not installed and maintained in accordance with Chapter 8 of NFPA 101 - 2000:

1) Corrected 04/16/10

2) Corrected 11/18/09

3) Modified 11/18/09: The provider indicated that the 2nd Floor SNF unit on 2 West is separated from the rest of the building by a two hour fire barrier (not necessarily required). The surveyor notes that 2 West is separated from the rest of the floor by a smoke barrier (rating unknown).

a) Deleted 04/16/10

b) The Life Safety Code Master Plans will need to be revised to accurately show complying smoke and fire barriers for the 2nd Floor (based upon the PoC for the Hospital and the PoC for the SNF Unit). See also K025

c) (04/16/10 - Modified from above): The current Life Safety Master Plans identify a smoke barrier at 2 South. The designated smoke barrier is deficient; the south wall of the Beauty Shop is missing above the ceiling. See also K025

If the smoke barrier remains on the Life Safety Master Plans, correction will be required. If a complying two hour fire smoke barrier is installed, as required by a Long Term Care Surveyor, at 2 North and the 2 South smoke barrier is deleted from the plans, correction at 2 South will not be required. The Life Safety Plans will need to be revised to show the revised smoke compartment sizes and the reviews locations of fire and smoke barriers.

4) (Modified 04/16/10) The single door behind the 2nd Floor Center Nurse's Station, to the SNF activity room has a magnetic hold open device. The wall is a required two hour fire barrier and possibly a required smoke barrier.

The door hold open lacks local smoke detection in accordance with 7.2.1.8. This was not corrected in accordance with the last submitted PoC. A smoke detector has not been installed within five feet of the door.

A) Based upon random observation from testing and the lack of documentation, the surveyor finds that some sprinkler control valves are not supervised electronically and many are not tested at least annually in accordance with NFPA 25.

1) The annual sprinkler system documentation of testing (and/or any other testing performed) does not provide an list item-by-item list of each tamper switch tested along with a pass/fail analysis. A list of the total number of devices tested vs the total number existing was also not available. The forms are not filled out completely and the documentation is incomplete. The surveyor could not determine what has been tested.

2) Corrected 11/18/09

3) Corrected 11/18/09

A) Based upon random observation, the surveyor finds that HVAC systems, fire dampers, smoke dampers, etc. are not installed in accordance with NFPA 90A:

1) Corrected 11/18/09

2) Corrected 11/18/09

3) Corrected 04/16/10




26665


A) Based on random observation, the surveyor found access panels in ductwork which contained fire protection devices (fire dampers, smoke dampers, duct detectors, etc.) that were not identified with letters 1/2" high identifying the type of fire protection device with-in as required by NFPA 90A 1999 2-3.4.2. Locations include but are not limited to;

1) Corrected 11/18/09
2) Corrected 11/18/09.
3) Corrected 04/16/10

B) Based on observation, the surveyor found locations where air intakes were installed less than 3' above the roof surface, air filters not sealed to prevent bypass and filter banks installed with no device to monitor pressure drop across the filters as required by NFPA 90A and ASHRAE Chapter 7.

4/16/10: the PoC does not appear to address the filter deficiencies and monitoring deficiencies cites above.

1) Corrected 11/18/09
2) Corrected 11/18/09
3) Corrected 11/18/09
4) Corrected 11/18/09
5) Corrected 04/16/10

6) The second floor mechanical room AHU's air intakes were observed to be less than 3' above the roof surface.

04/16/10: The above item was not corrected in accordance with the last submitted PoC. A 01/08/10 final correction date was identified in the PoC.

A) Based on random observation, the surveyor found components of the linen and trash chutes which does not comply with NFPA 82 requirements for self -closing and latching.

1) The first floor trash chute door in the corridor does not latch as required by 3-2.4.2.

2) Corrected 04/16/10

3) The lower level trash collection room chute door does not latch as required by 3-2.4.2.

4) The lower level linen collection room chute door does not latch as required by 3-2.4.2.

5) The lower level trash collection room chute door was tied open with a wire which prohibits self-closing.

6) The lower level linen collection room chute door was tied open with a wire which prohibits self-closing.

A) From observation, the surveyors find that oxygen storage tanks are stored (place in rack and not in locations for immediate use) in rooms with combustibles and do not comply with NFPA 99. In rooms with sprinkler protection oxygen is stored closer than five feet to combustible. In rooms without sprinkler protection oxygen is stored closer than 20'-0" to combustibles. Locations include but are not limited to:

1) 4th Floor ICU Storage Room - not corrected 11/18/09 4/16/10 - not shown to surveyor.

2) Corrected 11/18/09

3) Corrected 04/16/10

A) The surveyors find that the facility has an outside bulk oxygen storage system that does not comply with NFPA 99 and NFPA 50:

1) Corrected 11/18/09

2) The nearby recycling shed and the combustibles within are not at least 25 feet from the oxygen tanks.

04/16/10 - revise the correction date for the above item.

B) From random observation the surveyors find that medical gas systems are not installed and maintained in accordance with NFPA 99 - 1999.

1) Corrected 11/18/09

2) Corrected 11/18/09

3) All floors with medical gas vacuum outlets in patient rooms or recovery spaces. Medical gas shut off valves were not found. The provider was not able identify the location of the vacuum riser shut off valves for each floor. Locations include but are not limited to:

a) 5th Floor Stage II Recovery spaces.

b) 4 East Bronchoscopy Room and 4 East
patient rooms.

c) Patient rooms of 3 North

4/16/10: The above items were not corrected in accordance with the last submitted PoC. A revised PoC either indicating what corrections are required or indicating why correction is not required, was not submitted prior to the correction date indicated in the PoC. The year of installation for each existing system is required to confirm that correction is not required.

4) Corrected 11/18/09

5) 5th Floor Surgical Unit.

a) Corrected 4/16/10

b) Pre-op and the Post operative
Recovery Room have medical air,
oxygen and vacuum medical gas vacuum
systems. The vacuum system lacks area
shut off valves.

c) O R # 7 and O R # 8 have have medical
gas vacuum system but lack room, area
or floor shut off valves.

d) Corrected 11/18/09

4/16/10: The above items were not corrected in accordance with the last submitted PoC. A revised PoC either indicating what corrections are required or indicating why correction is not required, was not submitted prior to the correction date indicated in the PoC. The year of installation for each existing system is required to confirm that correction is not required.

A) Based upon the limited information available and based upon random observation, the surveyors find that smoke barriers have duct penetrations that lack smoke dampers or combination fire smoke dampers in compliance with 19.3.7.3. The surveyors also note that the building is only partially sprinklered and does not comply with exception # 2 for sprinkler protection except for locations entirely within 5 East and 4 East)

1) Deleted 11/18/09

2) Deleted 11/18/09

3) Corrected 04/16/10

4) The designated two hour barrier at the entrance to 2 East has one or more duct penetrations with no combination fire/smoke dampers. This barrier is not identified on the Life Safety Code Plan as a two hour fire barrier, as a smoke barrier or both. One or both may be required.

5) Corrected 04/16/10

The surveyors find that above citations are examples only and not a comprehensive list. The surveyors also find that provider lacks a complete list of all fire dampers and smoke dampers with the locations identified.

04/16/10: The surveyor finds that some locations have smoke dampers and/or combination fire/smoke dampers with coil-op designs and a motor on top of the duct, while other dampers are pivoting type dampers with a pivot or axle running vertically through duct and a motor on top. The surveyor does not find documentation that shows that these fire dampers are tested and maintained in accordance with NFPA 90A.

Also the surveyor finds that the damper motor assembly is recess into the fire wall on top of the duct. This creates a void in the fire barrier of smoke damper in the barrier above the duct. The surveyor finds no information on site to show how this condition is smoke tight and/or fire rated.

A) Based upon random observation and document review that surveyors find that seven of seven elevators (all elevators except for two freight elevators) are not installed and/or tested in accordance with ANSI A17.3.

1) The provider lacks documentation demonstrating that every elevator is tested for automatic fireman's recall (floor and alternate floor) for every elevator, annually.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

2) (Modified 11/18/09): Elevator # 4 lacks automatic and manual recall in accordance with ANSI A17.3.

04/16/10: The above item was not corrected in accordance with the last submitted PoC. The PoC was not modified and resubmitted with a new correction date before the correction date identified in the last submitted PoC. The PoC for the above item msut providxe a detailed phasing schedule, with dates, that identifies how it will be brought into compliance or) it is to be disabled and walled off immeidately.

3) (New 11/18/07): Based upon direct observation the surveyor finds that Elevator 1, 2 and 3 lacks automatic recall to a designated alternate floor in accordance with ANSI A17.3. Activation of a 1st Floor Elevator Lobby smoke detect results in recall of the elevator to the 1st Floor with the doors opening to the floor or fire origin.

04/16/10: The above item was not corrected in accordance with the last submitted PoC. The PoC was not modified and resubmitted with a new correction date before the correction date identified in the last submitted PoC.