HospitalInspections.org

Based on observation and interview, the provider failed to meet the minimum construction standards of the Life Safety Code. Findings include:

1. Observation on 11/02/11 at 9:30 a.m. revealed the building was a five story, protected ordinary, Type III (211) structure with a wood roof. Interview with the facility engineer at the time of the observation revealed the fifth floor and wood roof were constructed in the 1940s when steel was scarce during World War II.

The facility meets FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to install positive latching hardware on two randomly observed doors (the Projects room corridor door 1464 and corridor door 2450 to therapy) and one randomly observed room (3495) had tape over the strike plate. Findings include:

1. Observation at 10:15 a.m. revealed corridor door 1464 for the Projects room was not equipped with positive latching hardware. Interview with the facility service manager at the time of the observation confirmed that finding.

2. Observation at 11:00 a.m. revealed room 3495 electrical closet corridor door had the strike plate covered with masking tape which prevented the door from latching into the frame. Interview with the facility service manager confirmed that finding. He removed the masking tape from the strike plate during the survey.

3. Observation at 1:15 p.m. revealed corridor door 2450 to therapy was not equipped with positive latching hardware. Interview with the facility service manager at the time of the observation confirmed that finding.

Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the Fluoro 1 treatment room. The inactive leaf of the double door did not latch into the door frame. Findings include:

1. Observation and testing at 4:00 p.m. on 11/01/11 revealed the slave leaf of the duplex corridor door to the Fluoro 1 treatment room did not have functioning positive latching hardware. The slave leaf had latching hardware that was supposed to latch into the top of the door frame upon closing of the active leaf. When the active leaf was closed the latching hardware in the slave leaf did not positively latch into the door frame. Interview with the facility service manager at the time of the observation confirmed that finding. He revealed the slave door latching hardware would need to be repaired.

Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the east wing. Two randomly observed doors (4306 and 2312) to the corridor would not close and latch. Findings include:

1. Observation and testing at 8:20 a.m. on 11/02/11 revealed the door from the fourth floor room marked laundry (room 4306) would not close and latch into the door frame under power of the automatic door closer when tested. Interview with the director of facility engineering at the time of the observation confirmed that condition.

2. Observation and testing at 8:58 a.m. on 11/02/11 revealed the door from the second floor room 2312 would not close and latch into the door frame under power of the automatic door closer when tested. Interview with the director of facility engineering at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The one hour fire-rated double-doors between the emergency department and the ambulance garage were not provided with positive latching hardware. Findings include:

1. Observation at 10:50 a.m. on 11/01/11 revealed the south leaf of the double one hour fire-rated doors was missing the latching hardware. Interview with the facility maintenance supervisor at the time of the observation indicated the latching portion of the panic hardware had been damaged. The door hardware was different than other panic hardware throughout the hospital, so replacement parts were on order. The maintenance supervisor indicated several parts were ordered, so further damages could be corrected in a timely fashion.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas for room 4411 and the fire pump room. Soiled utility room door 4411 would not close and latch. Numerous openings around pipe penetrations and conduits for the fire pump room one hour fire-rated separation wall were not sealed with an appropriate firestop material. Findings include:

1. Observation and testing at 8:45 a.m. revealed soiled utility room door 4411 was a one hour fire-rated door. The door would not close and latch upon actuation of the closer. Interview with the facility service manager at the time of observation confirmed that finding.

2. Observation at 2:45 p.m. on 11/01/11 revealed openings around numberous pipe and conduit penetrations of the fire pump room one hour fire-rated separation wall that were not firestopped with an approved material. Interview with the facility service manager at the time of the observation confirmed those findings.

Based on measurement and interview, the provider failed to maintain clear door widths of at least 32 inches for three of five sets of exit access doors. Findings include:

1. Measurement on 11/01/11 at 10:30 a.m. revealed the leaves for the double-doors between building 01 and building 02 were between 21 inches and 29 inches wide. The horizontal exit door on the fourth floor was 29 inches in clear width while the clear width on the first and second floors measured 21 inches. Interview with the facility engineer at the time of the measurement confirmed those conditions.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

Based on observation, testing, and interview, the provider failed to maintain 90 minute horizontal exit doors in operating condition for two randomly observed doors (the 90 minute cross-corridor doors directly to the west of the elevator on first floor and the 90 minute horizontal exit doors to the west of room G356) at the separation between building 01 and building 02 on the first floor. Findings include:

1. Observation and testing at 9:40 a.m. revealed the south leaf of the cross-corridor horizontal exit doors on the first floor to the west of the elevators did not completely latch when closed with the automatic door closer. Those doors were equipped with fire rated door hardware that had both top and bottom latching mechanisms. In order for those doors to meet their original fire rating both top and bottom latches must engage. Testing of that door revealed the bottom latch of the south leaf did not engage the strike in the floor when closed. Interview with the director of facility engineering at the time of the observation and testing confirmed that finding.

2. Observation and testing at 10:04 a.m. revealed both leaves of the horizontal exit doors on the first floor to the west of room G356 would not completely latch when closed with the automatic door closers. Those doors were equipped with fire rated door hardware that had both top and bottom latching mechanisms. In order for those doors to meet their original fire rating both top and bottom latches must engage. Testing of that door revealed the bottom latch of both leaves did not engage into any strikes in the floor when closed. Observation at the time of testing revealed no floor strikes were visible due to installation of different flooring materials. Interview with the director of facility engineering at the time of the observation and testing confirmed that finding.

Based on observation, testing, and interview, the provider failed to maintain the rating of hazardous areas for the four soiled linen holding rooms in each of the nursing towers. Findings include:

1. Observation and testing beginning at 8:30 a.m. through 4:00 p.m. on 11/01/11 revealed the corridor doors to the soiled linen holding rooms at the following locations would not close and latch with the operation of the closer:
*Adjacent to patient room 3-123 in the bone marrow unit.
*Adjacent to patient room 1-155.
*Adjacent to patient room 1-222.

The soiled linen carts were over 32 gallons in size with a density of over 0.5 gallon/square foot of area; the soiled linen holding rooms must be maintained as hazardous areas. Testing of the doors at those locations during the observation period revealed the soiled linen cart wheels were free-wheeling and would obstruct the active door from closing fully and prevent latching if not perfectly aligned with the corridor opening.

Interview with the facility service manager at the time of the observations confirmed those findings. He stated it appeared the doors would close and latch if the soiled linen carts were placed in the space flush with the back wall and with the wheels parallel to the corridor.

Based on observation and interview, the provider failed to maintain fire-rated doors in fire-rated walls in operating condition in accordance with Life Safety Code (LSC) 4.6.12.1. One randomly observed 90 minute fire-rated double-door assembly adjacent to the morgue in the two hour fire-rated wall between building 04 (main street) and building 06 (ancillary) in the basement did not have floor strike plates. Findings include:

1. Observation at 3:15 p.m. on 11/01/11 revealed the 90 minute fire-rated double door assembly adjacent to the morgue in the two hour fire-rated wall between building 04 (main street) and building 06 (ancillary) in the basement did not have floor strike plates for the hardware in accordance with LSC 4.6.12.1. The 90 minute fire-rated doors were equipped with top and bottom latching hardware. Interview with the facility service manager at the time of the observation confirmed that finding. Interview at 1:00 p.m. with the facility engineer during the exit interview revealed the two hour fire-rated wall at that location had other openings on the same floor and upper floors that were not protected with corresponding fire-rated opening protectives. Further discussion revealed revision of the facility fire-rated separation walls had been planned but had not been completed at the time of the survey.

I. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center (Plaza 1) 1001 E. 21st Street, was found not in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

A. Based on observation, testing, and interview, the provider failed to maintain 90 minute horizontal exit doors in operating condition. One randomly observed horizontal exit doors (the 90 minute cross-corridor doors to the connecting link) at the separation between building Plaza 1 and building 11 (Prairie Center) on the third floor did not latch when closed with the closer. Findings include:

1. Observation and testing at 3:50 p.m. on 10/31/11 revealed the cross-corridor horizontal exit doors on the third floor connecting the building to the connecting link of building 11 (Prairie Center) did not latch when closed with the closer. Interview with the director of facility engineering at that time revealed those doors were operated by the smoke detectors on either side. Further testing of those doors on 11/01/11 at 10:58 a.m. with the facility's fire alarm contractor revealed those doors did not latch when the smoke detectors were activated. Interview with the director of facility engineering at the time of the testing confirmed that finding.

II. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted on 10/31/11 through 11/03/11. Avera McKennan Hospital and University Center (Plaza 2) outpatient clinics (Suites 220, 300, 400, 401, and 601) 1301 S. Cliff Ave was found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

III. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center (Plaza 3) nephrology clinic and liver disease clinic, 1315 S Cliff Ave were found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

IV. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, New Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center outpatient clinics (Suites 100, 200, 230, and 350) (Prairie Center) 1000 E. 23rd Street, were found not in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

A. Based on observation and interview, the provider failed to maintain the integrity of one randomly observed two-hour wall (electrical closet 3261). Findings include:

1. Observation at 3:50 p.m. on 11/01/11 revealed one of the three four inch conduits in the two-hour wall on the backside of electrical room 3261 was not furnished with an intumescent fire-stop pillow. The intumescent fire-stop pillow for that conduit was laying in the cable tray just below the conduit. Interview with the director of facility engineering at the time of the testing confirmed that finding.

V. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, New Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center Avera McKennan behavioral health in patient/outpatient clinics (Suites 500 and 1500) W. 69th Street were found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

VI. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted From10/31/11 through 11/02/11. Avera McKennan Hospital and University Center Avera McKennan outpatient clinics (occupational therapy, physical therapy and speech pathology) 6701 S. Minnesota Ave. were found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

VII. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center Avera McKennan outpatient clinic 911 E. 20th St. (suite 500) were found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

VIII. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from10/31/11 through 11/02/11. Avera McKennan Hospital and University Center (Avera Outpatient Rehabilitation) 1910 West 69th Street were (Prairie Center)found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

IX. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center (Wellness Center) 3400 Southeastern Drive was found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

X. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center outpatient clinic 810 East 23rd Street was found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

XI. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center outpatient behavioral health clinic 2412 S. Cliff Street (suite 100) was found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

XII. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center (Avera Outpatient Rehabilitation) 6100 W. 41st Street was found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

The Provider must comply with the National Fire Protection Association (NFPA 99), Medical Facilities section 3-4.2.2.2 Emergency System.

Based on observation and interview, the provider failed to install an emergency battery powered lighting unit at the location of automatic transfer switches (ATS) 20 and 21 in the basement room B631. Findings include:

1. Observation at 3:30 p.m. revealed the provider failed to install an emergency battery powered lighting unit at the location of automatic transfer switches (ATS) 20 and 21 in the basement room B631. Interview with the facility service manager at the time of the observation confirmed that finding. He stated it appeared the location had never had a battery powered emergency light installed.

Based on observation and interview, the provider failed to maintain three feet of clear working space in front of the electrical panels in four of six randomly observed rooms with electrical panels. The provider must comply with the National Fire Protection Association (NFPA 70), National Electrical Code (NEC) article 110.26(A)(1) Depth of Working Space (see attachment). Findings include:

1. Observation beginning at 4:00 p.m. on 10/31/11 and ending at 11:00 a.m. on 11/02/11 revealed the following electrical panels had obstructed access:
*Panels ECRPL4-4-02A and ECRFU4-4-02A disconnect had four plastic storage totes containing halloween decorations stored on the floor in front of the electrical equipment. The floor was marked and a sign posted to keep the space in front of the electrical panels clear.
*Room 3132 (electrical closet) panels NGEPL-3-1-011, NGEPL-3-1-111, ELSPH-3-1-01, and NGEPH-3-1-011 had supplies stored in front of the panels.
*Room 2133 had a fiberglass ladder stored in front of the electrical panels.
*Electrical panel NGEPL-1-1-411 was obstructed by box storage. There was not a minimum three feet of clear working space provided at any electrical panel in the room.

Interview with the facility service manager at the time of the observations confirmed those findings. He further revealed none of the items obstructing the electrical panels were acceptable storage practices at the facility.

Based on observation and interview, the provider failed to meet the minimum construction standards of the Life Safety Code. Findings include:

1. Observation on 11/02/11 at 9:30 a.m. revealed the building was a five story, protected ordinary, Type III (211) structure with a wood roof. Interview with the facility engineer at the time of the observation revealed the fifth floor and wood roof were constructed in the 1940s when steel was scarce during World War II.

The facility meets FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to install positive latching hardware on two randomly observed doors (the Projects room corridor door 1464 and corridor door 2450 to therapy) and one randomly observed room (3495) had tape over the strike plate. Findings include:

1. Observation at 10:15 a.m. revealed corridor door 1464 for the Projects room was not equipped with positive latching hardware. Interview with the facility service manager at the time of the observation confirmed that finding.

2. Observation at 11:00 a.m. revealed room 3495 electrical closet corridor door had the strike plate covered with masking tape which prevented the door from latching into the frame. Interview with the facility service manager confirmed that finding. He removed the masking tape from the strike plate during the survey.

3. Observation at 1:15 p.m. revealed corridor door 2450 to therapy was not equipped with positive latching hardware. Interview with the facility service manager at the time of the observation confirmed that finding.

Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the Fluoro 1 treatment room. The inactive leaf of the double door did not latch into the door frame. Findings include:

1. Observation and testing at 4:00 p.m. on 11/01/11 revealed the slave leaf of the duplex corridor door to the Fluoro 1 treatment room did not have functioning positive latching hardware. The slave leaf had latching hardware that was supposed to latch into the top of the door frame upon closing of the active leaf. When the active leaf was closed the latching hardware in the slave leaf did not positively latch into the door frame. Interview with the facility service manager at the time of the observation confirmed that finding. He revealed the slave door latching hardware would need to be repaired.

Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the east wing. Two randomly observed doors (4306 and 2312) to the corridor would not close and latch. Findings include:

1. Observation and testing at 8:20 a.m. on 11/02/11 revealed the door from the fourth floor room marked laundry (room 4306) would not close and latch into the door frame under power of the automatic door closer when tested. Interview with the director of facility engineering at the time of the observation confirmed that condition.

2. Observation and testing at 8:58 a.m. on 11/02/11 revealed the door from the second floor room 2312 would not close and latch into the door frame under power of the automatic door closer when tested. Interview with the director of facility engineering at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The one hour fire-rated double-doors between the emergency department and the ambulance garage were not provided with positive latching hardware. Findings include:

1. Observation at 10:50 a.m. on 11/01/11 revealed the south leaf of the double one hour fire-rated doors was missing the latching hardware. Interview with the facility maintenance supervisor at the time of the observation indicated the latching portion of the panic hardware had been damaged. The door hardware was different than other panic hardware throughout the hospital, so replacement parts were on order. The maintenance supervisor indicated several parts were ordered, so further damages could be corrected in a timely fashion.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas for room 4411 and the fire pump room. Soiled utility room door 4411 would not close and latch. Numerous openings around pipe penetrations and conduits for the fire pump room one hour fire-rated separation wall were not sealed with an appropriate firestop material. Findings include:

1. Observation and testing at 8:45 a.m. revealed soiled utility room door 4411 was a one hour fire-rated door. The door would not close and latch upon actuation of the closer. Interview with the facility service manager at the time of observation confirmed that finding.

2. Observation at 2:45 p.m. on 11/01/11 revealed openings around numberous pipe and conduit penetrations of the fire pump room one hour fire-rated separation wall that were not firestopped with an approved material. Interview with the facility service manager at the time of the observation confirmed those findings.

Based on measurement and interview, the provider failed to maintain clear door widths of at least 32 inches for three of five sets of exit access doors. Findings include:

1. Measurement on 11/01/11 at 10:30 a.m. revealed the leaves for the double-doors between building 01 and building 02 were between 21 inches and 29 inches wide. The horizontal exit door on the fourth floor was 29 inches in clear width while the clear width on the first and second floors measured 21 inches. Interview with the facility engineer at the time of the measurement confirmed those conditions.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

Based on observation, testing, and interview, the provider failed to maintain 90 minute horizontal exit doors in operating condition for two randomly observed doors (the 90 minute cross-corridor doors directly to the west of the elevator on first floor and the 90 minute horizontal exit doors to the west of room G356) at the separation between building 01 and building 02 on the first floor. Findings include:

1. Observation and testing at 9:40 a.m. revealed the south leaf of the cross-corridor horizontal exit doors on the first floor to the west of the elevators did not completely latch when closed with the automatic door closer. Those doors were equipped with fire rated door hardware that had both top and bottom latching mechanisms. In order for those doors to meet their original fire rating both top and bottom latches must engage. Testing of that door revealed the bottom latch of the south leaf did not engage the strike in the floor when closed. Interview with the director of facility engineering at the time of the observation and testing confirmed that finding.

2. Observation and testing at 10:04 a.m. revealed both leaves of the horizontal exit doors on the first floor to the west of room G356 would not completely latch when closed with the automatic door closers. Those doors were equipped with fire rated door hardware that had both top and bottom latching mechanisms. In order for those doors to meet their original fire rating both top and bottom latches must engage. Testing of that door revealed the bottom latch of both leaves did not engage into any strikes in the floor when closed. Observation at the time of testing revealed no floor strikes were visible due to installation of different flooring materials. Interview with the director of facility engineering at the time of the observation and testing confirmed that finding.

Based on observation, testing, and interview, the provider failed to maintain the rating of hazardous areas for the four soiled linen holding rooms in each of the nursing towers. Findings include:

1. Observation and testing beginning at 8:30 a.m. through 4:00 p.m. on 11/01/11 revealed the corridor doors to the soiled linen holding rooms at the following locations would not close and latch with the operation of the closer:
*Adjacent to patient room 3-123 in the bone marrow unit.
*Adjacent to patient room 1-155.
*Adjacent to patient room 1-222.

The soiled linen carts were over 32 gallons in size with a density of over 0.5 gallon/square foot of area; the soiled linen holding rooms must be maintained as hazardous areas. Testing of the doors at those locations during the observation period revealed the soiled linen cart wheels were free-wheeling and would obstruct the active door from closing fully and prevent latching if not perfectly aligned with the corridor opening.

Interview with the facility service manager at the time of the observations confirmed those findings. He stated it appeared the doors would close and latch if the soiled linen carts were placed in the space flush with the back wall and with the wheels parallel to the corridor.

Based on observation and interview, the provider failed to maintain fire-rated doors in fire-rated walls in operating condition in accordance with Life Safety Code (LSC) 4.6.12.1. One randomly observed 90 minute fire-rated double-door assembly adjacent to the morgue in the two hour fire-rated wall between building 04 (main street) and building 06 (ancillary) in the basement did not have floor strike plates. Findings include:

1. Observation at 3:15 p.m. on 11/01/11 revealed the 90 minute fire-rated double door assembly adjacent to the morgue in the two hour fire-rated wall between building 04 (main street) and building 06 (ancillary) in the basement did not have floor strike plates for the hardware in accordance with LSC 4.6.12.1. The 90 minute fire-rated doors were equipped with top and bottom latching hardware. Interview with the facility service manager at the time of the observation confirmed that finding. Interview at 1:00 p.m. with the facility engineer during the exit interview revealed the two hour fire-rated wall at that location had other openings on the same floor and upper floors that were not protected with corresponding fire-rated opening protectives. Further discussion revealed revision of the facility fire-rated separation walls had been planned but had not been completed at the time of the survey.

I. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center (Plaza 1) 1001 E. 21st Street, was found not in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

A. Based on observation, testing, and interview, the provider failed to maintain 90 minute horizontal exit doors in operating condition. One randomly observed horizontal exit doors (the 90 minute cross-corridor doors to the connecting link) at the separation between building Plaza 1 and building 11 (Prairie Center) on the third floor did not latch when closed with the closer. Findings include:

1. Observation and testing at 3:50 p.m. on 10/31/11 revealed the cross-corridor horizontal exit doors on the third floor connecting the building to the connecting link of building 11 (Prairie Center) did not latch when closed with the closer. Interview with the director of facility engineering at that time revealed those doors were operated by the smoke detectors on either side. Further testing of those doors on 11/01/11 at 10:58 a.m. with the facility's fire alarm contractor revealed those doors did not latch when the smoke detectors were activated. Interview with the director of facility engineering at the time of the testing confirmed that finding.

II. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted on 10/31/11 through 11/03/11. Avera McKennan Hospital and University Center (Plaza 2) outpatient clinics (Suites 220, 300, 400, 401, and 601) 1301 S. Cliff Ave was found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

III. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center (Plaza 3) nephrology clinic and liver disease clinic, 1315 S Cliff Ave were found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

IV. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, New Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center outpatient clinics (Suites 100, 200, 230, and 350) (Prairie Center) 1000 E. 23rd Street, were found not in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

A. Based on observation and interview, the provider failed to maintain the integrity of one randomly observed two-hour wall (electrical closet 3261). Findings include:

1. Observation at 3:50 p.m. on 11/01/11 revealed one of the three four inch conduits in the two-hour wall on the backside of electrical room 3261 was not furnished with an intumescent fire-stop pillow. The intumescent fire-stop pillow for that conduit was laying in the cable tray just below the conduit. Interview with the director of facility engineering at the time of the testing confirmed that finding.

V. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, New Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center Avera McKennan behavioral health in patient/outpatient clinics (Suites 500 and 1500) W. 69th Street were found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

VI. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted From10/31/11 through 11/02/11. Avera McKennan Hospital and University Center Avera McKennan outpatient clinics (occupational therapy, physical therapy and speech pathology) 6701 S. Minnesota Ave. were found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

VII. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center Avera McKennan outpatient clinic 911 E. 20th St. (suite 500) were found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

VIII. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from10/31/11 through 11/02/11. Avera McKennan Hospital and University Center (Avera Outpatient Rehabilitation) 1910 West 69th Street were (Prairie Center)found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

IX. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center (Wellness Center) 3400 Southeastern Drive was found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

X. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center outpatient clinic 810 East 23rd Street was found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

XI. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center outpatient behavioral health clinic 2412 S. Cliff Street (suite 100) was found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

XII. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted from 10/31/11 through 11/02/11. Avera McKennan Hospital and University Center (Avera Outpatient Rehabilitation) 6100 W. 41st Street was found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

The Provider must comply with the National Fire Protection Association (NFPA 99), Medical Facilities section 3-4.2.2.2 Emergency System.

Based on observation and interview, the provider failed to install an emergency battery powered lighting unit at the location of automatic transfer switches (ATS) 20 and 21 in the basement room B631. Findings include:

1. Observation at 3:30 p.m. revealed the provider failed to install an emergency battery powered lighting unit at the location of automatic transfer switches (ATS) 20 and 21 in the basement room B631. Interview with the facility service manager at the time of the observation confirmed that finding. He stated it appeared the location had never had a battery powered emergency light installed.

Based on observation and interview, the provider failed to maintain three feet of clear working space in front of the electrical panels in four of six randomly observed rooms with electrical panels. The provider must comply with the National Fire Protection Association (NFPA 70), National Electrical Code (NEC) article 110.26(A)(1) Depth of Working Space (see attachment). Findings include:

1. Observation beginning at 4:00 p.m. on 10/31/11 and ending at 11:00 a.m. on 11/02/11 revealed the following electrical panels had obstructed access:
*Panels ECRPL4-4-02A and ECRFU4-4-02A disconnect had four plastic storage totes containing halloween decorations stored on the floor in front of the electrical equipment. The floor was marked and a sign posted to keep the space in front of the electrical panels clear.
*Room 3132 (electrical closet) panels NGEPL-3-1-011, NGEPL-3-1-111, ELSPH-3-1-01, and NGEPH-3-1-011 had supplies stored in front of the panels.
*Room 2133 had a fiberglass ladder stored in front of the electrical panels.
*Electrical panel NGEPL-1-1-411 was obstructed by box storage. There was not a minimum three feet of clear working space provided at any electrical panel in the room.

Interview with the facility service manager at the time of the observations confirmed those findings. He further revealed none of the items obstructing the electrical panels were acceptable storage practices at the facility.