HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 12:00 pm and 5:00 pm, while accompanied by the Facilities Director, Biomed Tech, and Med Tech II it was observed that the facility failed to provide adequate protection for the required fire/smoke separation at the vertical ELEVATOR SHAFT. The following deficiencies were identified:
1. GENERAL COMMENT on the presence of unsealed penetrations at fire and smoke rated partitions throughout the facility.
2. PENTHOUSES FOR ELEVATORS 1 & 2 as well as ELEVATORS 3 & 4 - There were openings in the 2 hour fire-rated shaft walls where large pipes penetrated.
3. ALL ELEVATOR SHAFTS - The required fire-rated sealant (continuous) was missing along the top and bottom of the shaft wall construction. This condition should be checked and corrected as required at all floor levels
3. GENERAL COMMENT ON MISSING LABELS AT FIRE-RATED DOORS - Labels for fire-rated doors were missing at multiple locations throughout the facility.

Based on observations made during the survey of the facility between the hours of 12:00 pm and 5:00 pm, while accompanied by the Facilities Director, Biomed Tech, and Med Tech II it was observed that the facility failed to provide any of the required Exit Signage for the Central Physical Plant portion of the facility.

Based on observations made during the survey of the facility between the hours of 12:30 pm and 5:00 pm, while accompanied by the Facilities Director, Biomed Tech, and Med Tech II the following items were observed:
1. EXTERIOR BIOHAZARD ROOM - There was no fire sprinkler piping system provided at this room as required to be compliant as a "fully sprinklered" facility.
2. The required trim pieces were missing at multiple sprinkler head locations throughout the facility.
3. There were surface mounted fluourescent fixtures blocking the spray pattern of the sprinkler head at multiple locations throughout the facility.
4. There were multiple HOUSEKEEPING CLOSETS where the sprinkler head spray pattern was being blocked by the horizontal portion of the sprinkler riser piping where it transitions from vertical to horizontal near the ceiling of the closet.
5. At CENTRAL STORAGE near the DOCK the VESTIBULE had no fire sprinkler piping system.
6. At CENTRAL STORAGE above the low VESTIBULE ceiling, the sprinkler head spray pattern was blocked by large piping.
7. Both ELEVATOR PENTHOUSES were missing fire sprinklers.

Based on observations made during the survey of the facility between the hours of 12:30 pm and 5:00 pm, while accompanied by the Facilities Director, Biomed Tech, and Med Tech II it was observed that the facility failed to provide a log indicating consistant and routine compliance with the required annual inspection of the automatic fire sprinkler system by a sprinkler contractor.

Based on observations made during the survey of the facility between the hours of 12:30 pm and 5:00 pm, while accompanied by the Facilities Director, Biomed Tech, and Med Tech II
it was observed that:

A. While it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistent, systematic compliance on the following issues and items:
1. Air filter change log.
2. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
3. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

B. xxxx

Based on observations made during the survey of the facility between the hours of 12:00 pm and 5:00 pm, while accompanied by the Facilities Director, Biomed Tech, and Med Tech II it was observed that the facility failed to meet with the requirement for the Life Safety Branch circuitry. The following LIFE SAFETY electrical panels had deficiencies as noted below:
1. LIFE SAFETY PANEL " HPCP/LS " - Circuit No. 7 (for a 9 KUA transformer) should not be on the LIFE SAFETY BRANCH.
2. LIFE SAFETY PANEL " LPCP/LS " - The circuitry provide for the " TIME CLOCK " as well as the circuitry provided for the " EXHAUST FANS " have incorrectly been placed on the LIFE SAFETY BRANCH.