HospitalInspections.org

A. Based on review of the Life Safety Plans dated 10/09/09, based on random observation during the survey of February 5 through 8, 2013 and based on personnel interview including the Director of Engineering, the Director of Safety and the Director of Corporate Facilities the surveyor finds that portions of two buildings do not comply with 19.1.6.2.

Findings include.

1. Modified 06/11/13: Stair 7 is a two story stair in the 400 building that is not an exit. The stair is part of the one story (with Basement) portion of the 400 Building that is identified as Type I construction. The stair has a unrated monolithic ceiling with unrated access panels. The stair has unprotected steel floor structure above. The provider was unable to demonstrate that all of teh seel above the ceiling was fire proofed. This stair has unprotected roof structure/penthouse (projecting above the roof of teh 400 Buidling) which is not compatible with the designated construction type for the building and does not comply with 19.1.6.2.

2. The Emergency Room portion one story addition is Type II (000) construction. The adjacent 1st Floor Lab is part of the 5 story, 400 building to the north. The 400 Building is identified as Type I (332) construction; however, a continuous two hour fire barrier is not identified separating all portions of the building with Type II (000) construction from the Type 1 Building. This reduces the construction type of the 400 Building to Type II (000) construction. The 400 building therefore does not comply with 19.1.6.2.

3. The provider identified a portion of the 1st Floor as Nuclear Medicine. The surveyor was not able to identify which building this space is located; However, the surveyor observed fire-proofed steel above the ceiling in Nuclear Medicine and observed unprotected steel in the corridor south of this space. The surveyor did not find a two hour fire barrier between these differing construction types.

4. Corrected 6/11/13

A. Based on review of the Life Safety Plans dated 10/09/09, based on random observation during the survey of February 5 through 8, 2013 and based on personnel interview including the Director of Engineering, the Director of Safety, the Director of Corporate Facilities, and the facilities architectural consultant, the surveyor finds that portions of two buildings do not comply with 19.1.6.2.

Findings include.

1. The Interconnecting Building/wing has been cited in this survey as part of the 350 Building. It connects the 350 Building to the 400 Building and is separated from the 400 Building by a two hour fire barrier. It is five stories in height and it is Type I (332) construction. This wing is only partially sprinklered on each floor.

The Building identified as the Emergency Room/Imaging Addition is a one story building of Type II (000) construction. It was built immediately north of the Interconnecting Wing and extends partially under the Interconnecting Wing at Central Waiting. This building may or may not be fully sprinklered.

The surveyor finds no evidence of a two hour fire separation between the 350 Building [that is Type I (332) Construction] and the one story addition that is identified as the Emergency Room/Imaging Addition [that is Type II (000) construction]. Based on this the surveyor finds that the 350 Building is five stories in height, is Type II (000) construction and does not comply with 19.1.6.2.

Modified on 06/11/13: Based on onsite information, the surveyor finds that the Type II (000) building to the west extends under the 2nd Floor, Type I construction system for the Connecting Link of the 350 Building, at the 1st Floor, without a two hour fire separation. Sprinkler protection does not change this citation.

2. The 1st Floor of the 350 Building has a pair of fire doors into the 400 Building opposite Room D155. A portion of the 350 building in front of these fire doors has unprotected structural steel [Type II (000) construction] in an area that is surrounded by two buildings that are both Type I construction.

06/11/13: The above item was not corrected. Two bar joist remain unprotected above the ceiling.

3. (New 06/11/13): The roof structure above the Solarium on the east side of the building is constructed of exposed steel studs, exposed steel C joists and plywood roof sheathing.

a. These materials are not compatible with
Type II (222) and/or Type I (332) - the
identified construction type for this
building.

b. This attic space has combustible
materials in a concealed space and lacks
sprinklered protection in accordance 5
13.1.1 of NFPA 13 - 1999.

All construction types are based on NFPA 220 and not on ICC.

end

Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that areas that are open to exit access corridors do not comply with 19.3.6.1 of NFPA 101 - 2000.

Findings include:

1. The 1st Floor Central Waiting area is a very large waiting area on both sides of a corridor. It includes a cafe food serving area and multiple seating areas. It is sprinklered throughout. The areas open to the corridor are not supervised 24/7 and the smoke detection installed does not cover every part of the area open to the corridor in accordance with 19.3.6.1, exception # 1 and NFPA 72.

6/11/13: Although the provider indicated that the above item was corrected, the surveyor finds that two additional smoke detectors are needed at the south end of the space in order to comply with the spacing requirements of NFPA 72 and one smoke detector is missing from the skylight area.

A. Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the 2nd Floor of the 350 Building has multiple patient room doors with white isolation boxes hung on the corridor side of the doors. These boxes obstruct the door opening width to less than 41 ½ " clear opening (typically only 39 " to 40 " ) and do not comply with 18.2.3.5 (the door widths may not be diminished below what they were designed as unless they exceed 41 1/2").


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B. Corrected 06/10/13

Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the Interconnect Wing on Floors 2 through 5 link the 350 Building to the 400 Building and are used for inpatient movment. Although the provider identifies these wings as business occupancies, the surveyor finds that they are health care occupancies because patients are moved in beds through the wings.

1. Each floor has continuous storage closets on one side of the corridor. Each closet door has a dead-bolt lock that is not positive or automatic latching in accordance with 19.2.6.2.

Based on observation and an interview, it was determined that the facility failed to maintain the doors and hardware per NFPA 101, Section 39.2.2.2 and 7.2.1. In the event of a fire the occupants may not be able to exit and escape from smoke and fire.

Findings include:

On 2/7/13, 2nd floor, during the walk through of the facility with the Director of Engineering, it was observed that the double cross corridor doors separating the psych office and the means of egress.One door contains a non-functional hardware (knob), and can not be opened without opening the second door first. The operation of the doors is not clear and the doors lack signage indicating which door is functional. The current arrangement does not meet with the requirements of NFPA 101, 7.2.1.5.5.

UPDATE 6/10/13: The doors were not provided signage and the hardware has not been replaced as stated in their POC dated 4/24/13.

Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds vertical openings are not protected in accordance with 8.2 of NFPA 101

Findings include:

1. The Basement Mechanical Room for the 400 Building has a vertical shaft that penetrates three or four floors. The shaft has an insulated duct inside. The shaft may be an air intake shaft. The shaft does not comply with 8.2:

a. Deleted 06/11/13.

b. The shaft enclosure is used for storage; this does not comply with NFPA 90A.

c. The roof of the shaft appears to be wood/lumber (construction that is not compatible with the construction type identified for the 400 Building).

UPDATE 6/11/13: No corrective measures have been completed for this citation, and was not in compliance with the Plan of Correction submitted on 4/24/13.

Based on random observation during the survey walk-through, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 39.3.1. This deficient practice would allow a fire to spread without proper fire separation and affect all occupants in the building.

Findings include:

1. On 2/7/13, Basement Mechanical room, by EKG, during the walk through of the facility with the Director of Engineering, it was observed that the mechanical room contains a triangular shaft at the block wall. The fire rating could not be determined from the Life Safety Code drawings and the access door was constructed of wood and not fire rated, 8.2.3.2.3.1.

2. On 2/7/13, 5th floor, Mechanical Room, during the walk through of the facility with the Director of Engineering, it was observed that the mechanical room contains several large unsealed floor penetrations.


3. On 2/7/13, 2nd floor, during the walk through of the facility with the Director of Engineering, it was observed the staff area, back wall, is a designated 2 hour rated building separation from the 400 building. The wall contains a door to a patio, utilized by both business and hospital psych. The wall contains a ventilation shaft which is not complete as a fire rated shaft enclosure above the ceiling tiles and does not meet 39.3.1.1.

Based on observation and the minimal drawings provided by the facility staff, there were multiple unsealed penetrations in the walls designated as one hour walls on the floor plans.

1. On 2/08/13 in the morning, based on observations, surveyor with Director of Engineering observed multiple unsealed penetrations at the designated one hour wall separating the tenant floors from the two story Lobby in Outpatient Care Center.

Based on observations, there were multiple unsealed penetrations in the wall designated as the one hour wall separating the Pavilion floors from the two story Main Entrance and Lobby.

1. On 2/07/13 surveyor observed tube system pipe penetrations above the toilet room nearest to Outpatient Registration that were not sealed for fire rated construction.
UPDATE 6/10/13: The following is a clarification to the location of the citation above. In reference to the life safety code drawings provided, the unsealed rated wall runs along the back wall of the toilet room near "holding room" and across from treatment room #1.

2. On 2/07/13, based on surveyor observations, there were multiple sleeves that were not sealed by fire rated construction in the floor of the Telecommunications Room on the Second Floor behind the elevators.

3. On 2/07/13, based on surveyor observations, there were unsealed penetrations in the designated one hour rated walls between the two story lobby and the Telecommunications Room on the Second Floor behind the elevators.
UPDATE 6/10/13: The following is a clarification on the location of the citation above. In reference to the life safety code drawings provided, the back wall is designated as 2 hour fire rating and contained unsealed penetrations.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed doors with hold open devices do not comply with 19.2.2.2.6 and 7.2.1.8: Findings include:

1. Clean Utility Room A540 is large enough to be a hazardous area. The corridor door to the room has a magnetic hold open device but lacks smoke detection within five feet of the door.

2. 5th Floor pair of fire doors between the 350 Building and the East Building at the north connection. The fire doors took to much time to close to latch upon activation of the fire alarm system and at least one of the doors did not latch.

6/10/13: The above item was not corrected in accordance with the last submitted PoC.

Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that fire doors with hold open devices are not installed to comply with 7.2.1.8 of NFPA 101.

Findings include:

1. 1st Floor Dietary Dry Storage Room: One pair or more of doors to this hazardous area have magnetic hold open devices but lack local smoke detection on each side of the doors that will detect smoke and release the doors.

06/11/13: A smoke detectors is not installed of the door on hold open devices between the walk-in coolers - Storage to Kitchen.

2. Corrected 06/11/13

3. The pair of fire doors from the South Lobby to the Cafeteria failed to close and latch upon activation of the fire alarm system. One door failed to close to latch due to air pressure.

06/11/13: both doors failed to close and latch upon activation of the fire alarm system.

Based on observations of hazardous areas the facility failed to properly separate combustible stored materials from building occupants. The separation between hazardous areas and the means of egress failed to meet with the requirements of NFPA 101, (2000), Section 39.3.2.1 and 8.4.1.1. This deficient practice would allow a fire to spread without proper fire separation and affect all occupants in the smoke zone.


Findings include:

A. On 2/7/13, 5th floor, Medical Records Room, during the walk through of the facility with the Director of Engineering, the room was found to have a high combustible fuel load of open paper files, cardboard boxes in a room not sprinkler protected. The door and walls to the Medical Records Room are deficient because:

1. The door to the room did not have an automatic door closer. (8.4.1.3 and 7.2.1.8)
2. The door was not a 3/4 hour fire rated with appropriately listed hardware (8.4.1.3)
3. A 1-hour rated enclosure could not be verified (8.2)

B. Corrected 6/10/13
C. Corrected 6/10/13

E. On 2/7/13, 3rd floor, during the walk through of the facility with the Director of Engineering, it was observed that the waiting area contains an abandoned optometrist office, which is separated from the waiting room by frosted glass panels. The room is currently being used for general storage and does not comply with the requirements for a one hour fire rated enclosure under NFPA 101, 39.3.2.1 and 8.4

F. On 2/7/13, 3rd floor, during the walk through of the facility with the Director of Engineering, it was observed that the reception area contains, sliding racks of open files. The general storage of the files is not separated from the waiting area and exit route or protected in accordance with Section 8.4.

Based on observations of hazardous areas the facility failed to properly separate combustible stored materials from the exit egress corridors. This required separation between hazardous areas and exit access corridors is to be in accordance with the requirements of NFPA 101, 2000 Edition, Section 18.3.2.1 and 8.2.3.2.3.1(2). This deficient practice would allow a fire to spread without proper fire separation and affect all occupants in the smoke zone.


Findings include:

1. Corrected 06/11/13

2. On 2/5/13 at 8:52 AM, 1st Floor Surgery, Equipment Room (E170) during the walk through of the facility with the Director of Engineering, it was observed the door failed to close and latch.

Hazardous area was not separated in a tenant space, as required by LSC Section 8.2.3.2.3.1(2).

On 2/07/13, in the afternoon, surveyor observered during the walk through with the Director of Engineering, that the Medical Records Room in the Ob/Gyn Office on the Fourth Floor was not separated. The door leading from Medical Records to the Nurse's Station was held open with a wedge.

UPDATE 6/10/13: During the walk through, the door was once again wedged open. The corrective action of "reinforced in our annual training" has not been an effective.

A. Based on observation on February 7, 2013, with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that exit enclosures are not installed and maintained to provide a continuous, safe path to public way in accordance with Chapter 7 of NFPA 101 - 2000.

1. Corrected 06/11/13

2. Stair S10 at the Basement Level does not comply with 7.1.3.2.1 of NFPA 101:

a. There is a large pump recessed into the
stair floor at the Basement Level.

b. There is a 16" x 16" metal box on the
stair wall at the intermediate landing
between the Basement and 1st Floor.
The provider did not know what the box
was and/or how it is permitted in the
stair enclosure.

3. Corrected 06/11/13

4. On 06/11/13 the surveyor observed a chair and a cardboard box which was left on teh 5th Floor landing of Stair S10. This was not found and abated by the provider's interim life safety measures.

A. Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that exit enclosures are not installed and maintained to provide a continuous, safe path to public way in accordance with Chapter 7 of NFPA 101 - 2000.

Findings include:

1. Stair # 1 is located at the south end of the 350 Buildings and serves as a required exit for the 1st Floor through the 5th Floor (all are patient floors). The stair discharges into a 1st Floor Required Exit Passageway that is located entirely with the South Building (Bldg 06). The Exit Passageway is roughly 140' in length and does not comply with 7.1.3.2.1, 7.1.3.2.2, and 7.2.6 of NFPA 101. The surveyor observes that this building is only partially sprinklered at best.

a. A significant portion of this exit passageway has a monolithic ceiling. The provider had no details for this ceiling and did not know when it was constructed. It appears to be installed to provide a two hour barrier separating unapproved systems and penetrations above. However, the monolithic ceiling is suspended from above by channels and wire that are not protected as two hour support assemblies (8.2.3.1).

06/11/13: The PoC for the above item does not clearly indicate the the suspension system will be removed.

b. The monolithic ceiling has access panels that are not permitted under 7.1.3.2.1 d).

06/11/13: The PoC for the above item does not clearly indicate when the ceiling was constructed as a fire barrier in an exit enclosure and how the access panels are permitted.

c. Corrected 06/11/13

d. The first vestibule in this exit passageway is in front of the 1st Floor Morgue. The walls at this locations do not extend above the ceiling of the Morgue as two hour barriers to the deck above.

e. An exit sign in the exit passageway identifies an exit path, to the west south of the Morgue, that is not an exit passageway.

f. Deleted 06/11/13

g. The south end of the exit passageway has paper faced batt insulation above the lay-in ceiling at this location. The space is at least partially sprinklered; however, the space above the ceiling (concealed space with combustible materials - paper faced fiberglass batt insulation ) is not sprinklered in accordance what NFPA 13.

h. The pair of doors to Materials Management (F190) lack U L Labels as 90 minute fire doors.

i. The door to Biohazard (F176) lacks U L Labels as 90 minute fire doors.

j. The Materials Management Building is a Type II (000) structure with metal walls. The provider lacks detailed information that identifies how this area is separated from the exit passageway by a two hour barrier.

k. The Loading Dock area is newer construction and is Type II (000). The provider lacks detailed information that demonstrates how the interior Loading Dock space is separated from the exit passageway by a two hour barrier that includes the top of wall termination detail.

06/11/13: The PoC for the above item indicates that a two hour shaft wall is installed instead of "a two hour shaft wall will be installed."

Adequate interim life safety measures were not found for the above condition.

2. Corrected 06/11/13.

a. Corrected 06/11/13

b. Corrected 06/11/13

c. Corrected 06/11/13

d. Corrected 06/11/13

3. Deleted 06/11/13

Based on observations, the facility failed to provide exit components having a fire resistance rating of at least two hours. The exit components are not arranged to provide a path of escape, and to provide protection against fire or smoke from other parts of the building.

Findings include:

On 2/5/13 at 9:15 AM, during the walk through of the facility with the Director of Engineering, it was observed that the 1st floor, Stair Door (Stair S17) did not close and latch as required by NFPA 101, 18.3.1 and 8.2.5.4(1).

Based on observations, the facility failed to provide exit components having a fire rating equal to that of the stair, as required by Section 7.2.6.3.

On 2/07/13, surveyor observed penetrations in the First Floor exit passageway from Stair 1 to the exterior. There were several unsealed openings around penetrations above the the door into the exit passageway from the the Outpatient Treatment Area on the East.

Based on observations, the facility failed to provide stairs and exit components having a fire resistance rating of at least two hour. The exit components are to be arranged to provide a path of escape, and to provide protection against fire or smoke from other parts of the building. NFPA 101, 39.2.2.3 and 7.2.2.

Findings include:

1. On 2/7/13, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that the exit stair (Stair S14) off of the 5th Floor elevator lobby does not comply with Chapter 7 of NFPA 101. The stairwell landing contains a door to a small room which contains a water heater. Doors opens into a normally unoccupied room and is not permitted to open into a rated exit stair per NFPA 101, Section 7.1.3.2(b) and 7.2.2.5.3.

2. On 2/7/13, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that exit stair (S14) is required to be a 2 hour rated enclosure based on NFPA 101, 39.3.1.1 and 8.2.5.4(1). The stair enclsoure wall(s) to roof/deck connection were observed not to be sealed with a UL fire rated product. This condition was observed on all floors for this stairwell.

3. On 2/7/13, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that exit stair (S15) is required to be a 2 hour rated enclosure based on NFPA 101, 39.3.1.1 and 8.2.5.4(1). The wall to roof/deck connection was observed not to be sealed with a UL fire rated product. This condition was observed on all floors for this stairwell

4. On 2/7/13, 4th floor, during the walk through of the facility with the Director of Engineering, it was observed that Stair S14 has stair doors that swins into the stairwell at the stair landing, obstructing the landing. The distance between the guard rail and the edge of the door provides an 8 " clearance. The current arrangement restricts anyone from the upper floor from proceeding down the stairs during an evacuation. The stair does not meet with NFPA 101, 7.2.2.3.2 or provide an unobstructed path of egress. This condition was observed on Floors 2 through 4.

Based on observation, of two stairs serving the upper level of this building, two of the exit stairs were found to be deficient and not in compliance with Chapter 7 of NFPA 10.

1. On 2/08/13, surveyor with Director of Engineering observed that the enclosed stairs from the Cardiac Rehab Mezzanine to grade were used to store holiday decorations.

2. corrected 6/11/13

A) (New 06/11/13) The surveyor finds that the Loading Dock on the south side of the building has an unprotected drop off of 30" or more. A exit path is directed with exit signs to a stair next to the Loading Dock. Safety chains or effective barriers are not installed and maintained to keep people using this exit path from walk off the Loading Dock.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed that the means of egress to a public way is not maintained in accordance with Chapter 7 of NFPA 101.

Findings include:

1. Corrected 06/11/13

2. 2nd Floor - Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the 2nd Floor of the 350 Building has a 50 foot dead end corridor near Room A227. There is no exit sign at the north end of the corridor.

06/11/13: Not enough information is provided in the PoC. The surveyor also notes that the existing suite has an exit path north to south with an exit sign above a doors that also indicates " no admittance " .

a. The corridor terminates at a pair of doors that extend into a vacant suite.

b. Corrected 06/11/13

c. The suite is not supervised 24/7 and cannot serve as the exit path from a corridor The suite does not currently comply with the rules for corridors or suites.

06/11/13: Not enough information is provided in the PoC.

d. Corrected 06/11/13

3. Corrected 06/11/13

4. Modified 06/11/13: There is one pair of cross corridor doors in the 1st Floor corridor near Room A103 with magnetic locking devices. The provider proposes to use the 15 second delay requirements under 7.2.1.6.1. The PoC indicates that this item has been completed; however the space lacks sprinklered protection in accordance with 7.2.1.6.1.

5. Corrected 06/11/13



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B. Corrected 06/11/13

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyor finds that exit paths are not maintained and readily accessible at all times in accordance with 7.1.

1. The 1st Floor Emergency Department has locking devices that do not comply:

a. Corrected 06/11/13

b. Corrected 06/11/13

c. Corrected 06/11/13

d. The 1st Floor Emergency Department
has two seclusion Room that share a
toilet room. The toilet room has two
doors each with a single cylinder dead
bolt lacks that lacks a thumbturn inside
for each lock.

2. The Emergency Department has an exit path that is directed with exit signs into the Ambulance Bay/Drive-thru Canopy area.

a. Corrected 06/11/13

b. The exit path towards the Ambulance
Bay/Drive Thru has exit signs above two
pairs of doors that do not swing in the
designated direction of exit travel in
accordance with 7.2.4.2.

c. The interior vestibule space between the
Ambulance Bay and the Emergency
Department is a large storage space that
is not separated from the Emergency
Department and the exit path by one
hour construction in accordance with
19.3.2.1 and 19.3.6.1.

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyors find that exit paths are not maintained and readily accessible at all times in accordance with 7.1.

Findings include

1. The 5th Floor Rehab Suite is an inpatient treatment area. The exit access corridor from this suite to Exit Stair S11 lacks two remote exit paths in accordance with 19.2.6.2.4.

a. The required exit path to Stair S10 to the
west is not available and is not marked
with illuminated exit signs.

b. The two hour separation for the suites to
the west is not identified as a horizontal
exit nor is it identified as a smoke
barrier. The doors swing only in one
direction. Opposite swinging doors are
not provided for the required exit paths
in both directions.

c. The two hour barriers to the west cannot
comply as a horizontal exit. The doctor's
suites are business occupancies in a
health care area, on a health care floor, in
a health care building and the suites do
not comply with 19.2.6.2.4. Note: This
floor is not sprinklered.

d. Suite 510 and 504 have only one exit
path. The corridor lacks two remote
paths and does not comply with
19.2.6.2.4.

e. Suite 504 blocks access to Stair S10.
The suite is locked during some hours
and an exit access corridor through the
suite is not provided.

f. Suite 504 is open to the exit access
corridor to the east above the skylight.
This arrangement does not comply with
19.3.6.2.1.

06/11/13: The PoC indicates that the
above item has been corrected. This
item is tied to item "g' below and it
has not been corrected.

g. Suite 504 has open file storage in the
reception area that is also open to the
entire suite and the exit access corridor
to the east. This arrangement does not
comply with 19.3.2.1, 19.3.6.1. and
19.3.6.2.1.

06/11/13: The PoC does not clearly
indicate that the file storage area will
be separated from all other areas in
accordance with 19.3.2.1

2. Corrected 06/11/13

2. Corrected 06/11/13

3. There is a required exit access corridor in the Ambulatory Area (corridor shown between a suite that is 3550 GSF and a suite that is 4644 GSF - corridor number is not legible on the plans provided. The corridor lacks two remote exit paths in accordance with 19.2.5.9. The designated exit path to the North is through a horizontal exit into a 9807 square foot suite (OPS Holding and Post Op/Cardiac Cath). This path does not comply with 19.2.6.2.4. The path is the suite from the Horizontal Exit exceeds 100' of travel to a corridor door and therefore cannot serve as a 2nd remote exit path from the corridor cited.

06/11/13: The travel distance identified above is measures from the most remote point in the suite to a corridor door. The door to an exit does not meet the requirements for a primary path of travel from a suite. The above item has not been corrected.

4. There is a pair of cross corridor doors with an exit sign above the doors (somewhere near Room D185). The doors have magnetic locking devices and a sign on the door identifying 15 second delay. The doors also have a sensor above the door that release the locks immediately when approved. The doors do not comply with 7.2.1.6.1 and/or 7.2.1.6.2

a. The sign identifying the door as a
delayed egress doors is not legible (not
enough contrast). Nor is the sign
accurate (the sensor releases the door
immediately).

b. There is a sensor above the doors that
releases the locks; however a push to
exit device is not installed strictly in
accordance with 7.2.1.6.2. The provider
is not able to demonstrate how the doors
will release and comply with 7.2.1.6.1 if
the sensor fails.
.

Based on observations and interview the facility failed to provide all exit discharge paths meeting the requirements of NFPA 101, 39.2.7 and 7.7.

Findings include:

1. On 2/7/13, 1st floor, Stair S14 and S15. Exit stairs continuing beyond level of discharge were not provided with interrupter gate as required by NFPA 101, 7.7.3.

2. Corrected 6/10/13

Based on observations the facility failed to provide exit access that is readily accessible to a public-way at all times. Obstructions during an emergency situation could be fatal if this were the only escape route.

Findings include:

On 2/5/13 at 2:30 PM, during the walk through of the facility with the Director of Engineering, it was observed that the 1st Floor LDR corridor door to exit Stair S16, contains a delayed-egress lock. The door was equipped with 15-second delayed-egress lock, and the sign posted on the door indicated that you must " push " until alarm sounds, " door can be opened in 15 seconds " . The door was equipped with a standard lever door knob; it was unclear as to what you " push " to release the door lock and operation of the latchset does not release the lock. The arrangement does not meet with NFPA 101, 7.2.1.6.1.

06/11/13: Although the PoC does not indicate such, the provider indicated that the item was corrected. However, it was found to not be corrected.

A. (Modified 06/10/13): Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed a elevator vestibule - space (the vestibule is not identified as a suite) that is east of the 5th Floor ICU Suite. This vestibule has a pair of fire doors to the East Building that lacks a sign that indicates "not an exit" on the west side of these doors, in accordance with 7.10.8. Also, the pair of doors at the east edge of the 350 Building lacks a sign on the pair of doors, on the west side of the doors, that indicates not an exit. There is no exit path to the east beyond these doors.

B. Corrected 06/10/13

C. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that 3rd Floor Interconnect Wing lacks an illuminated exit sign to the east.

Surveyor note - Item C may or may not be corrected - surveyors notes do not indicate that this item was looked at during this visit.

A. Based on observation February 6, 2013, with the Director of Corporate Facilities and the Director of Biomed and Safety present, and based upon review of the Life Safety Plans dated 10/09/09, the surveyor finds the following:

1. The 4th Floor of the 400 Building is a business occupancy. It is not fully sprinklered. Two new exit stairs in the East Building are not accessible from the 4th Floor of the 350/400 Buildings. Stair S10 is located behind a locked suite and is not accessible from all parts of the 4th Floor. This leaves only two stairs (including S5) in the 400 Building both of which discharge into the interior of the building at the 1st Floor. Neither of these stair comply with 7.7.1. The 350 Building has two stairs that comply with 7.7.1 and one stair that complies with 7.7.2.

06/11/13: The PoC for teh above item does not comply. The same conditions may apply also to the 3rd Floor. Niether of these floors are sprinklered; the common path of travel for the area identified does not comply with 39.2.4.2. The nearby two hour fire barrier is not a horizontal exit; it does not compty with 7.2.4.3.1, exception (c).

Text Deleted 06/11/13

Text Deleted 06/11/13

2. Corrected 06/11/13




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B. Corrected 06/11/13

Based on observation with the Director of Safety and the Director of Corporate Facilities 02/07/13, the surveyor finds that illuminated exit signs are not provided in accordance with 7.10 of NFPA 101.

Findings include

1. Corrected 06/11/13

2. (New 06/11/13) 1st Floor E R Triage area - a 2nd means of egress from this space is not clearly identified with an illuminated exit sign.

1. On 6/11/13 observations determined that the directional exit sign at the Entry to the Cancer Treatment Center from the Plaza Building was not visable due to building component (beam / soffit) obstruction. This lack of visual indication during an emergency could lead to confusion as to the location of exits by guests and residents and does not meet with NFPA 101, 7.10.1.7.

The facility failed to mount exit signs where they are not obstructed by other building components as required by LSC Section 7.10.1.7.

1. On 2/07/13, at 4:20 PM, based on observations during the walk through and by interview with the Director of Engineering, it was agreed that the exit sign and area of refuge signs were not clearly visible behind the arches in the central corridor of the 5th Floor tenant spaces. These signs were mounted in the corridor near the door to Stair No. 1 and are not visible.

2. On 2/07/13, at 4:25 PM, based on observations during the walk through and by interview with the Director of Engineering, it was agreed that the exit sign and area of refuge signs were not clearly visible behind the arches in the central corridor of the 6th Floor tenant spaces. These signs were mounted in the corridor near the door to Stair No. 1 and are not visible.

Based on document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During a review of the facility's fire protection plan documents, including Life Safety Plans dated 10/09/09, it was determined that the facility has not prepared and maintained comprehensive building information, which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Corrected 06/10/13

2. Corrected 06/10/13

3. Corrected 06/10/13

3. Corrected 06/10/13

4. Smoke barrier walls; The Life Safety Plans dated 10/09/09 that were furnished by the provider for the survey do not clearly identify the size of smoke compartments for each floor or zone. Further the plan key identifies smoke barriers and one, two and three hour smoke resistant walls. The smoke barriers and ratings are not clearly identified. The Plan Key does not clearly indicate that the smoke resistant walls are intended to identify smoke barriers.

5. Hazardous area enclosures and their fire resistance ratings.

6. Corrected 06/10/13

7. Corrected 06/10/13

8. All exit access corridors.

10. Corrected 06/10/13

11. Corrected 06/10/13

06/11/13 - Note: the above items and all items previously cited will remain open for further review on future onsite visits

Based on document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During a review of the facility's fire protection plan documents, it was determined that the facility has not prepared and maintained comprehensive building information, Life Safety plans and/or construction documents which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Ventilation, duct, and pipe shafts and their fire resistance ratings.

2. Barriers for two story spaces

3. Elevator shafts with fire ratings

3. Fire barrier walls and/or horizontal exits.

4. Tenant separation barriers

5. Exits and exit enclosures

6. Hazardous area enclosures and their fire resistance ratings.

7. Accurate and current information identifying the extent of sprinklered protection of the building.

8. Information at a scale that is large enough to read.


UPDATE 6/11/13: This tag remains because the drawings provided to the surveyor were small (8 1/2" x 11") and were not legible. The surveyor could not determine the wall designations from the information provided.

Based on document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During a review of the facility's fire protection plan documents, it was determined that the facility has not prepared and maintained comprehensive building information, Life Safety plans and/or construction documents which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Ventilation, duct, and pipe shafts and their fire resistance ratings.

2. Barriers for two story spaces

3. Elevator shafts with fire ratings

3. Fire barrier walls and/or horizontal exits.

4. Tenant separation barriers

5. Exits and exit enclosures

6. Hazardous area enclosures and their fire resistance ratings.

7. Accurate and current information identifying the extent of sprinklered protection of the building.

8. Information at a scale that is large enough to read.

UPDATE 6/11/13: This tag remains because the drawings provided to the surveyor were small (8 1/2" x 11") and were not legible. The surveyor could not determine the wall designations from the information provided.

Based on document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During a review of the facility's fire protection plan documents, it was determined that the facility has not prepared and maintained comprehensive building information, Life Safety plans and/or construction documents which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. corrected 6/11/13.

2. Barriers for two story spaces

3. corrected 6/11/13

3. Fire barrier walls and/or horizontal exits.

4. Tenant separation barriers

5. corrected 6/11/13

6. corrected 6/11/13

7. Accurate and current information identifying the extent of sprinklered protection of the building.

8. Information at a scale that is large enough to read.


UPDATE 6/11/13: New drawings were provided, but failed to clarify how the tenant spaces are seperated from the two story lobby area. The "atrium" lobby space contains an open Stair A001-A002 which connects the main level to the second level. It could not be determine which section of NFPA 101, 8.2.5 (vertical openings) the two story space complies with.

Based on document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During a review of the facility's fire protection plan documents, including Life Safety Plans dated 10/09/09, it was determined that the facility has not prepared and maintained comprehensive building information, which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Identification of construction types, as defined by NFPA 220, for each different part of the building. Separations between buildings are not clearly defined. There are a lot of two hour barriers that do not define building separations. In some cases, it is not clear which building an area is part of

2. Deleted 06/11/13

3. Deleted 06/11/13

3. Fire barrier walls and/or horizontal exits.

4. Smoke barrier walls; The Life Safety Plans dated 10/09/09 that were furnished by the provider for the survey do not clearly identify the size of smoke compartments for each floor or zone. Further the plan key identifies smoke barriers and one, two and three hour smoke resistant walls. The smoke barriers and ratings are not clearly identified. The Plan Key does not clearly indicate that the smoke resistant walls are intended to identify smoke barriers.

a. Life Safety Plan identify two hour smoke barriers in the middle of the 2nd Floor Psychiatric Unit. Two hour smoke barriers were not found.

06/11/13: No PoC was found for the above item

5. Deleted 06/11/13.

6. Deleted 06/11/13

7. Designated suites, suite boundaries

a. The Life Safety Plans for the 2nd Floor Psychiatric Unit does not clearly identify suites and exit access corridors.
The corridor adjacent to Room 251 is not clearly identified as part of a suite and is not identified as an exit access corridor. This corridor is shown terminating at a suite (with 3095 square feet). This corridor does not comply with 19.2.5.9 and the two hour barrier at the west end of the corridor does not qualify as a horizontal exit.

The corridor between the 3000 square foot suite and the 3450 square foot suite is a required exit access corridor. This corridor terminates at the same 3095 square foot suite that is identified in item a above. This corridor also does not comply with 19.2.5.9.

Based upon item "a" and "b" the surveyor finds that the Boys Psychiatric Unit (3095 GSF) was not designed to be a suite and it is mis-identified on the plans. An exit access corridor through this space to Stair S10 is required and is not identified on plans.

No exit access corridors are identified for the 2nd Floor of the 400 Building.

b. Corrected 06/11/13

c. Corrected 06/11/13

8. All exit access corridors.

10. Deleted 06/11/13

11. Deleted 06/11/13

06/11/13: All items are under futher review on future visits.




end

Based on document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During a review of the facility's fire protection plan documents, including Life Safety Plans dated 10/09/09, it was determined that the facility has not prepared and maintained comprehensive building information, which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Identification of construction types, as defined by NFPA 220, for each different part of the building. Separations between buildings are not clearly defined. There are a lot of two hour barriers that do not define building separations. In some cases, it is not clear which building an area is part of

2. Deleted 06/11/13

3. Deleted 06/11/13

3. Fire barrier walls and/or horizontal exits.

a. The Life Safety Plans identify two hour walls at Storage Room B131. Two hour barriers were not found.

4. Smoke barrier walls; The Life Safety Plans dated 10/09/09 that were furnished by the provider for the survey do not clearly identify the size of smoke compartments for each floor or zone. Further the plan key identifies smoke barriers and one, two and three hour smoke resistant walls. The smoke barriers and ratings are not clearly identified. The Plan Key does not clearly indicate that the smoke resistant walls are intended to identify smoke barriers.

5. Deleted 06/11/13

6. Deleted 06/11/13

7. Designated suites, suite boundaries

a. The Life Safety Plans identify three 1st Floor Suites in the Emergency Department; however no suite boundaries are identified.

b. Exit access corridors are not clearly identified and the travel distance from some patient treatment areas in each suite appears to exceed 100' to a corridor door (or door directly to the outside. (19.2.5.8) In some cases that travel distance exceeds 50' where the path pass through two spaces to get to a corridor door (19.2.5.8). The Life Safety Plans provided for this survey are not scalable.

8. All exit access corridors.

10. Deleted 06/11/13

06/11/13: The above items will be under further review on future onsite visits.

Based on document review for the previous 12 months, the facility failed to perform fire drills at least once per quarter per shift.

1. On 2/05/13 at 4:00 PM with Director of Biomed and Safety, the surveyor observed that no drill was conducted during the third shift for the Second Quarter of 2012 as required by LSC Section 19.7.1.2.

06/11/13: Fire drill documentation will continue to be reviewed on the next onsite visit.

A. The facility failed to provide a fire alarm system to give effective warning of a fire in accordance with NFPA 72.

1. Corrected 06/10/13

2. On 2/07/13 in the afternoon during the fire alarm testing, surveyor observed that the fire alarm was not audible in the short corridor between the two sets of cross corridor doors at the West end of the Labor/Delivery Unit, and outside patient room A103.

UPDATE 6/11/13: A speaker was not installed at this location and when the doors close during the fire alarm test, the speaker in the elevator lobby is not loud enough to meet with the level standard for this section of the corridor.

A. Based on document review and interview of the project architect of record, the surveyor finds that the East Tower is new health care occupancy and is required to be fully sprinklered in accordance with 18.3.5.1. The new building is fully sprinklered; however, it is not separated from the 350 Building by two hour fire rated construction and portions of the 350 Building are not sprinklered.

Findings include:

1. Corrected 06/11/13

2. The 1st Floor of the East Tower is separated from the unsprinklered portions of the 1st Floor of the 350 Building by a one hour smoke barrier and not a two hour fire barrier. Based on the Life Safety Plans dated 10/09/09 and based on direct observation with the Director of Safety present, the surveyor finds that portion of the 1st Floor of the 350 Building are not sprinkled, therefor the East Tower does not comply with 18.3.5.1.

end

A. Based on observation on 02/05/13 - 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that sprinkler systems are not installed and maintained in accordance with NFPA 13.

1. Corrected 06/10/13

2. (New 06/11/13): The South Canopy at the south entrance is not sprinklered. The provider lacks signs that indicate that unattended vehicles may not be left under this unsprinklered canopy.




12799


B. The facility did not provide a sprinkler system that was installed and maintained in accordance with NFPA 13.

1. On 2/05/13, surveyor with Director of Biomed and Safety observed the sprinkler piping above Patient Room 518 does not have an arm-over bracing to prevent uplift as required by NFPA 13, 1999 Edition, Section 6-2.3.4 or 6-2.1.3.

2. Corrected 06/10/13

3. Similar conditions were observed by the surveyors on other floors in closets in the Interconnecting Wing between Stair S3 and Stair S5 (example: closet at west end of corridor near Elevator D).

A. Based upon random observation with the Director of Biomed/Safety and the Director of Corporate Facilities and based on document review of Life Safety Plans date 10/09/09, the surveyor finds that the sprinkler system is not installed at maintained in accordance with NFPA 13 and NFPA 25:

Findings include:

1. Corrected 06/11/13

2. Corrected 06/11/13

3. Corrected 06/11/13

4. Deleted 06/11/13

5. The Basement corridor between Stair S5 and S11 has a continuos pipe chase that runs parallel to the corridor. This pipe chase is open to the corridor ceiling and is not separated from the corridor above the ceiling. The pipe chase is used for storage. The pipe chase is accessible as defined by NFPA 13. The pipe chase and the area open to the pipe chase above the corridor ceiling is not sprinklered in accordance with NFPA 13.

6. corrected 6/11/13
7. corrected 6/11/13

Based on observation the facility failed to install and maintain automatic sprinkler protection in accordance with the requirements of NFPA 101, 2000 Edition, NFPA 13, 1999 Edition, as well as NFPA 25, 1998. Findings include:

1. On 6/11/13 observations determined that in the 2 story lobby area outside of the ASC (suite 1100) a sprinkler head was missing an escutcheon plate.The missing escutcheon plate leaves a hole in the ceiling and compromises the rated ceiling. NFPA 25, 2-4.1.8.

2. On 6/11/13 observations determined that in the 2 story lobby area outside of the ASC (suite 1100), on the stair landing to 2nd floor a ceiling tile was not seated in the grid .The opening leaves a penetration in the ceiling and compromises the ceilings ability to control smoke / fire. NFPA 13, 5-6.4.1.1.

Based on observations and interviews it was determined that the facility failed to properly manage and maintain the existing Air-conditioning and Ventilating Systems per NFPA 101, 2000, 39.5.2. Section 2.1, Mandatory References: This code section requires the facility to be in compliance with the NFPA 90A, Standard for the "Installation of Air-conditioning and Ventilating Systems", 1999 edition.

Findings include:

A. On 2/7/13, Basement, EKG mechanical room, observations and interviews during the walk through of the facility with the Director of Engineering, it was determined that the room contains several (3 or 4) large ducts that penetrate the back wall which contain fire dampers.

1. Corrected 6/10/13
2. Corrected 6/10/13

3. Fire dampers require a 4-year inspection / exercise / clean / lubricate / rest fusible link, per NFPA 90A, Section 3-4.7 Maintenance. The facility failed to provide documentation that the dampers were inspected or maintained in the last 4-years.

A. Based on document review for Kitchen Hood Suppression systems, for semi-annual inspection, testing and maintenance for the past 12 months, the surveyor finds that the documentation for both kitchen hoods (Main Kitchen and Servery) does not comply with NFPA 17A and NFPA 96.

Findings include:

1. Deleted 06/11/13

2. The documentation for the Main Kitchen and Servery is combined on one form for each semi-annual inspection. The documentation does not identify specifically the appliances protected under each hood and the documentation does not identify the number or type of links that were replaced for each system.

3. Corrected 06/11/13



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B. Corrected 06/11/13

Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyors observed that the facility did not provide and/or maintain commercial cooking equipment in accordance with 9.2.3.

1. On 2/05/13 at 1:30 PM, surveyors observed that the Outpatient Therapy Kitchen the 5th floor near the doors to the Restorative Services Department in the 400 Building has a working stove, but does not have a Class K fire extinguisher as required by NFPA 10, 1998 Edition, Section 3-7.1.

06/11/13 - the above item was not corrected in accordance with the last submitted PoC.

2. Corrected 06/10/13

Based on observation with the Director of Safety and the Director of Corporate Facilities the surveyor finds medical gas tanks are not stored in accordance with NFPA 99 - 1999.

Findings include:

1. Basement Level of the 400 Building. Respiratory has oxygen tanks that are stored closer than 5'-0" to combustibles.

2. (New 06/11/13) The surveyors observed that the Physical Therapy area is not sprinklered. The Hydro-therapy area had oxygen tanks which were stored in this space, closer than 20'-0" from combustibles and not in accordance with NFPA 99.

The surveyor finds on the afternoon of 2/5/13 while in the company of the Director of Plant Operations and Maintenance on the First Floor (350 Building), medical gas zone valve installed (Well Born Nursery work room 127) within the same space as the outlets they serve (Room 127A) in noncompliance with NFPA 99, 1999, 4-3.1.2.3.

06/11/13 - the attachment submitted with the last PoC was too small to read. Not enough information is provided.

The surveyor find on the afternoon of 2/5/13 while in the company of the Director of Plant Operation & Maintenance at the Basement Level (East Building), unrelated electrical equipment (maintenance shop air compressor & public address system amplifier) installed within the medical gas manifold room (304) as prohibited by NFPA 99, 1999, 4-3.1.1.2, (a) 10.

UPDATE 6/11/13: The maintenance shop air compressor has been removed from the medical gas manifold room however, the unrelated electrical equipment remains.

The surveyor finds on the morning of 2/6/13 while in the company of the Director of Plant Operations and Maintenance on the First Floor (400 Building), medical gas zone valve installed (Clinical Decision Unit) within the same space as the outlets they serve in noncompliance with NFPA 99, 1999, 4-3.1.2.3.

The surveyor finds the morning of 2/6/13 while in the company of the Director of Plant Operations and Maintenance, by direct observation and staff interview it could not be confirmed the location of the medical gas zone valves serving treatment bays 12 & 13 of the Emergency Room (Imaging/ER Building). NFPA 99, 1999, 4-3.1.2.14, (b).

Based on random observation during the survey walk-through while accompanied by the lead engineer and the building operations manager , the surveyor found that 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 without the facility being aware that the emergency generators are not functioning properly.

Findings include:

1. The pavilion emergency generator did not have a remote shut down switch to comply with NFPA-110, Section 3-5.5.6.

2. The pavilion generator did not have a remote annunciator or a derangement signal at a 24 hour staffed location to meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

UPDATE 6/10/13: The previous plan of correction indicated that "it is considered a Type 2 system". NFPA 70, 99 and/or 110 requires that a Type 2 system comply as a Level 1 generator set and requires constant monitoring and a remote shut down as previously stated in the deficiencies to meet the code requirements.

A. Deleted 06/11/13

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.

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.

06/11/13: Interim Life Safety Measures were reviewed onside. The provider has conducted in service training of staff and implemented a fire watch. The frequency of the fire watch was once every eight hours. The surveyors find that adequate interim life safety measures were not implemented where cited under each K-tag.





12799

B. Corrected 06/10/13

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) Adequate interim life safety measures were not found for K033, K038 and K047.

Based on random observation during the survey walk-through while accompanied by the lead engineer and the building operations manager, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 99 (1999).

Findings include:

All medical gas system alarm points are not monitored at the master alarm panel at a continuously attended location in accordance with NFPA-99, Section 4-3.1.2.2(b)2 and (b)3.

A. Based on observation February 8, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed that electrical installations and materials do not comply with NFPA 70 - 1999.

Findings include

1. Corrected 06/11/13

2. 06/11/13 Dietary: access to Panel N40 was blocked by storage

3. 06/11/13 Dietary: access to Panel N438 and N39 was blocked by shelving in front of the panels





17659

B. Based on random observation during the survey walk-through while accompanied by the lead engineer and the building operations manager, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. The generator room was not equipped with any electrical receptacles served by the life safety branch of the emergency power as required by NFPA-70, Section 517-32. These may be needed to perform maintenance on generators during an extended power outage.

2. corrected 6/11/13

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyor finds that electrical installations and materials are not installed and maintained in accordance with NFPA 70 - 1999.

Findings include:

1. Corrected 06/11/13

2. (Modified 06/11/13): The 5th Floor Rehab Suite has a fish tank with an electrical extension cord that does not comply with NFPA 70

3. (Modified 06/11/13): 1st Floor Imaging Department - the MRI Equipment Room has multiple items that obstructs access to an electrical panel. 3'-0" of clear space in front of all panels and switches is not maintained in accordance with NFPA 70.

4. 1st Floor Cardiac Cath Area (near doors to the north): Data cables and electrical cables are supported by plumbing pipes above the ceiling and they are supported by the lay-in ceiling. These installations do not comply with NFPA 70.

5. Corrected 06/11/13

6. Corrected 06/11/13

7. Corrected 06/11/13

8. Corrected 06/11/13

B. Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that two or three cath labs were in use and could not be inspected. Cath Lab # 3 was inspected and does not comply wit h NFPA 70-1999 and NFPA 99 -1999.

a. Corrected 06/11/13

b. The surveyor observed no
electrical outlets that are supplied
only from normal electrical power
in accordance with NFPA 99,
3-3.2.1.2 (a) 1 and 517-19 of NFPA
70 - 1999. This deficiency could
cause injury to patients due to
transfer switch failure.

06/11/13: The PoC for the above
item does not clearly indicate how it
complies, or how it will be corrected
and when it will be corrected.

The provider was not able to demonstrate that the same conditions would not be found in Cath Lab # 1 and # 2

Based on observations, the facility failed to install electrical wiring in accordance with NFPA 101, 39.5.1, Section 9.1.2 as well as NFPA 70, 1999 Edition, National Electrical Code.

Findings include:

1. On 2/7/13, 3rd floor, in the elevator lobby, above the ceiling tiles by the Neurology Office is a Junction box that lacks a cover plate, which does not meet with NFPA 70 (1999) 370-25.

2. On 2/7/13, 2nd floor, in the elevator lobby, above the ceiling tiles by the Cardiac office corridor is a Junction box that lacks a cover plate, which does not meet with NFPA 70 (1999) 370-25.

Based on random observation during the survey walk-through while accompanied by the lead engineer and the manager of building operations, portions of the elevator control system are not installed in accordance with ASME without the proper safety devices installed.

Findings include:

1. Corrected 06/11/13

2. Deleted 06/11/13

3. The surveyor observed that the elevator machine room for elevator 6 and 7 was not 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 A17.3-102.2.c.3.

a. 06/11/13: The PoC does not clearly
identify that a shut trip relay is installed
and tested. A heat detector is not
installed within two feet of each
sprinkler head. This incudes heat
detectors that are not installed within
two feet of each sprinkler head in the
storage room adjacent to the elevator
machine room (the door between these
two spaces is not a fire door without a
louver).

b. 06/11/13: There is a beam in or near the
above elevator machine room with
missing fire proofing. Also, the elevator
machine room is open to an adjacent
space (not the storage room identified
above). This adjacent space lacks a
sprinkler head in accordance with NFPA
13 and a heat detector, as indicated
above.

4. (Modified 06/11/13): The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects for elevators 6, and 7 as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.

06/11/13: The PoC does not accurately describe how the above item was or will be corrected.

5. (New 06/11/13) With the exception of Elevator # 5 (the Morgue Elevator) and Elevator 6 and 7, the surveyor finds that most if not all elevator machine rooms have heat detectors only installed but lack smoke detectors which are specifically installed to recall elevators in accordance ASME A17.3-211.3.