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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) Corrected 08/04/10.

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.

NEW 08/04/10: The pair of doors to the Ambulance Bay were observed to have been modified in the field by the provider; thus the doors' fire resistance ratings had been compromised.

3) Corrected 11/17/09

4) Corrected 08/04/10.

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) Corrected 08/04/10.

NEW 08/04/10: The pair of doors at the south end of the North Wing Corridor (east of the Elevators), which is locked under patient elopement conditions, was observed to lack a delayed agress mechainsm as required by 7.2.1.6.1.

4) Corrected 04/16/10

5) Corrected 11/18/09

6) Corrected 08/04/10.

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) Corrected 08/04/10.

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) Corrected 08/04/10.

7) Corrected 11/18/09

8) Corrected 08/04/10.

9) Corrected 08/04/10.

Surveyors note 08/30/10 - no sprinkler shop drawings or working documents submitted as of this date. Project 9041 submittal remains incomplete.






26665


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

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) Corrected 08/04/10.

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. Corrected 08/04/10.

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. Corrected 08/04/10.

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) 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) Corrected 08/04/10.




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) Corrected 08/04/10.

2) Corrected 08/04/10.

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) Corrected 08/04/10.

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.