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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.

Update 03/18/14: The steel floor structure above the stair was observed to be fire proofed.

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.
UPDATE 8/15/13: This is the same location as Bldg. 1 -K12-1 and Bldg. 2 -K12-A2

Update 03/18/14: Based on personnel interview the PoC provided for Item 3 was intended for a different deficiency. A PoC for this deficiency was not provided.

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. Corrected 03/18/14

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 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. Corrected 8/14/13

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 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. Corrected 03/18/14
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. Corrected 8/14/13
F. Corrected 8/14/13

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. Corrected 03/18/14

3. Corrected 06/11/13

4. Corrected 8/14/13
.

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. Corrected 03/18/14

b. Corrected 03/18/14

c. Corrected 06/11/13

d. Corrected 03/18/14

e. Corrected 8/14/13.

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.

Update 03/18/14: The paper faced insulation was replaced with unfaced insulation laid on top of a suspended grid ceiling. During inspection plywood roof sheathing was observed above the new insulation and was thus exposed to the exit passageway.

h. The pair of doors to Materials Management (F190) lack U L Labels as 90 minute fire doors.
UPDATE 8/14/13: the doors and frame are not located in the rated wall assembly.

Update 03/18/14: The doors were observed to be located in the fire rated wall assembly but were not equipped with a mechanism to ensure that the two leafs close without being hindered by the astragal.

i. Corrected 8/14/13

j. Corrected 03/18/14

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.

Update 03/18/14: The doors were observed to be located in the fire rated wall assembly, but the top of wall termination detail was not complete. The interim life safety measures provided with the PoC were observed to be in effect.

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 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. Corrected 03/18/14

3. Corrected 03/18/14

4. Corrected 03/18/14

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. Corrected 03/18/14

d. Corrected 06/11/13

3. Corrected 06/11/13

4. Corrected 03/18/14

5. Corrected 06/11/13



12799


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. Corrected 03/18/14

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.

Update 03/18/14: The PoC provided a completion date of 2/28/14 for item 2c. Work assocated with this item was not complete.

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. Corrected 03/18/14

b. Corrected 8/14/13

c. Corrected 03/18/14

d. Corrected 03/18/14

e. Corrected 03/18/14

f. Corrected 03/18/14

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. Corrected 03/18/14

4. Corrected 8/14/13

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




12799


B. Corrected 06/11/13

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 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).

Update 03/18/14: The medical gas zone valves were observed to be labeled.

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.

Update 03/18/14: The interim life safety measures provided with the PoC were observed to be in effect.




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.

Update 03/18/14: The interim life safety measures provided with the PoC were observed to be in effect.

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.

Update 03/18/14: The interim life safety measures provided with the PoC were observed to be in effect.

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. Corrected 8/14/13
3. (Modified 06/11/13): Corrected 8/14/13

4. Corrected 03/18/14

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