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Based on observation and interview, it was determined the facility failed to maintain construction type requirements, in one of thirty-nine smoke zones within the component.

Findings include:

1. Observation on March 6, 2019, at 10:10 AM revealed structural steel was missing fireproofing (monocoat) inside the shaft, by Door G007.

Interview at the time of the exit conference with the Director of Plan Operations & Maintenance, Operations Director and the Regional VP of Administration on March 6, 2019, at 2:15 PM confirmed fireproofing was missing off structural steel.

Based on observation and interview, it was determined the facility failed to maintain the rating of the stairtower, in one of two stairtowers within the component.

Findings include:

1. Observation on March 7, 2019, at 10:31 AM revealed an unsealed conduit above the ceiling, at the rear stairtower door on the 2nd floor.

Interview at the time of the exit conference with the Director of Plan Operations & Maintenance, Operations Director and the Regional VP of Administration on March 7, 2019, at 11:00 AM confirmed the conduit was not sealed.

Based on observation and interview, it was determined the facility failed to maintain the 2-hour fire resistance rating of horizontal exits in one location, on one of five floors within the component.

Findings include:

1. Observation on March 5, 2019, at 2:00 PM revealed the 3rd floor 2-hour horizontal exit wall, at Double Doors 3232A, was not sealed to the exterior wall, the floor deck above and the left side of the I-beam, closest to the courtyard, on both sides of the wall.

Interview with the Director of Engineering and Construction and Maintenance Supervisor on March 5, 2019, at 2:00 PM confirmed the unsealed 2-hour fire rated wall.

Based on observation and interview, it was determined the facility failed to maintain the corridor to be clear and unobstructed, in one of three floors within the component.

Findings include:

1. Observation on March 7, 2019, at 10:37 AM revealed specimen boxes were on both sides of the corridor, at Suite 332.

Interview at the time of the exit conference with the Director of Plan Operations & Maintenance, Operations Director and the Regional VP of Administration on March 7, 2019, at 11:00 AM confirmed the corridor width had been diminished.

Based on observation and interview, it was determined the facility failed to maintain the rating of the suite separation, in two of ten smoke zones within the component.

Findings include:

1. Observation on March 7, 2019, at 10:10 AM revealed a large cutout in the drywall of the suite separation, between the Cancer Center and the corridor, at the smoke barrier doors.

Interview at the time of the exit conference with the Director of Plan Operations & Maintenance, Operations Director and the Regional VP of Administration on March 7, 2019, at 11:00 AM confirmed the suite separation was incomplete.

Based on observation and interview, it was determined the facility failed to maintain exiting signage, as it was contradictory, in one of nine stairtowers within the component.

Findings include:

1. Observation on Mach 5, 2019, at 1:47 PM revealed a "No Exit" sign was hung across the interior of a stairtower, marked as an exit, from the ground floor and the 1st floor.

Interview at the time of the exit conference with the Director of Plan Operations & Maintenance, Operations Director and the Regional VP of Administration on March 5, 2019, at 2:15 PM confirmed the signs were in contradiction of each other.

Based on observation and interview, it was determined the facility failed to maintain the rating of hazardous areas, in one of thirty-nine smoke zones within the component.

Findings include:

1. Observation on March 5, 2019, at 1:32 PM revealed the ceiling was incomplete, in the Central Storage Room by the Boiler Room exhaust fan, where a 5-inch conduit came through the ceiling.

Interview at the time of the exit conference with the Director of Plan Operations & Maintenance, Operations Director and the Regional VP of Administration on March 5, 2019, at 2:15 PM confirmed the ceiling was not smoke tight.

Based on observation and interview, it was determined the facility failed to maintain sprinkler system components, in one instance, on one of five floors within the component.

Findings include:

1. Observation on March 6, 2019, at 10:45 AM revealed a sprinkler head was covered with fire protectant over spray, in the 2nd floor West Mechanical Room by AHU 1.

Interview with the Director of Engineering and Construction and the Maintenance Supervisor on March 6, 2019, at 10:45 AM confirmed the sprinkler was heavily loaded with fire protectant over spray.

Based on observation and interview, it was determined the facility failed to maintain the corridor, to resist the transfer of smoke, in one of thirty-nine smoke zones within the component.

Findings include:

1. Observation on March 5, 2019, between 1:48 PM and 2:04 PM revealed the corridor ceiling was incomplete, at the following locations:

a. 1:48 PM, ground floor outside Mechanical Room G-61;
b. 2:04 PM, ground floor at Elevators 3 & 4, at the electrical panels.

Interview at the time of the exit conference with the Director of Plan Operations & Maintenance, Operations Director and the Regional VP of Administration on March 5, 2019, at 2:15 PM confirmed the ceilings were incomplete.

Based on observation and interview, it was determined the facility failed to maintain corridor doors, to be free of obstruction from closing, in one of thirty-nine smoke zones within the component.

Findings include:

1. Observation on March 6, 2019, at 1:55 PM revealed a chair was being used to prevent the 2nd floor Maternity Staff Lounge from being closed.

Interview at the time of the exit conference with the Director of Plan Operations & Maintenance, Operations Director and the Regional VP of Administration on March 6, 2019, at 2:15 PM confirmed the door was obstructed.

Based on observation and interview, it was determined the facility failed to maintain the rating of the smoke barriers, in one of nine smoke zones within the component.

Findings include:

1. Observation on March 7, 2019, at 10:31 AM revealed a penetration, above the smoke barrier wall to the Atrium, on the left hand side.

Interview at the time of the exit conference with the Director of Plan Operations & Maintenance, Operations Director and the Regional VP of Administration on March 7, 2019, at 11:00 AM confirmed there was a penetration.

Based on observation and interview, it was determined the facility failed to maintain the rating of smoke barriers, in three of thirty-nine smoke zones within the component.

Findings include:

1. Observation on March 5, 2019, at 1:56 PM revealed a penetration of a gray wire, above the smoke barrier door G-36, on the Staff Locker Room side.

Interview at the time of the exit conference with the Director of Plan Operations & Maintenance, Operations Director and the Regional VP of Administration on March 5, 2019, at 2:15 PM confirmed there was a penetration.


2. Observation on March 6, 2019, at 11:15 AM revealed the following smoke barrier wall deficiencies, on the 4th floor Main Building, above double doors 4-8:

a) an unsealed white insulated pipe;
b) a large unsealed blow-out patch, located above the ductwork;
c) the wall was not continuous, between the double doors and the Waiting Room.

Interview with the Director of Engineering and Construction and the Maintenance Supervisor on March 6, 2019, at 11:15 AM confirmed the smoke barrier wall was incomplete.


3. Observation on March 6, 2019, at 1:05 PM revealed a penetration, above Smoke Barrier Door 1-235, on the Atrium side, where the caulk had been pulled out of the wall.

Interview at the time of the exit conference with the Director of Plan Operations & Maintenance, Operations Director and the Regional VP of Administration on March 6, 2019, at 2:15 PM confirmed there was a penetration.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors to be smoke tight, and to be self-closing, on one of five floors within the component.

Findings include:

1. Observation on March 6, 2019, at 10:00 AM revealed Smoke Barrier Doors G-003 had a gap, greater than an eighth of an inch, between the two panels.

Interview at the time of the exit conference with the Director of Plan Operations & Maintenance, Operations Director and the Regional VP of Administration on March 6, 2019, at 2:15 PM confirmed the smoke barrier doors were not smoke resistant.


2. Observation on March 6, 2019, at 11:40 AM revealed the smoke barrier door, to the 4th floor Main Building Cancer Risk Assessment and Genetics Office, lacked self-closing hardware.

Interview with the Director of Engineering and Construction and the Maintenance Supervisor on March 6, 2019, at 11:40 AM confirmed the door lacked a self-closure.

Based on document review and interview, it was determined the facility failed to maintain fire rated doors, throughout the component.

Findings include:

1. Review of documentation and interview on March 5, 2019, at 11:30 AM revealed the last annual fire door inspection, completed in August 2018, revealed the fire doors throughout the facility failed to pass testing and inspection. The doors identified as "failed" have not been corrected.

Interview with the Facility Representatives and the Maintenance Technician on March 5, 2019, at 11:30 AM confirmed numerous fire doors, throughout the facility, are in need of repair.

Based on observation and interview, it was determined the facility failed to maintain electrical switchgear rooms, in accordance with NFPA 70, 2011 Edition.

Findings include:

1. Observation on March 6, 2019, at 10:33 AM revealed the fire-rated wall, to the 2nd floor Main South Switchgear Electrical Room 2020A, was not complete to the exterior wall, in the back right corner, closest to the stair.

Interview with the Director of Engineering and Construction and the Maintenance Supervisor on March 6, 2019, at 10:33 AM confirmed the incomplete fire-rated wall.