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Based on observation and interview it was determined the facility failed to properly maintain one 2-hour fire rated common wall affecting one of one smoke compartment in this component.

Findings include:

A. Observation on September 9, 2011, at 3:22 PM, revealed the ground floor double set of doors serving the 2-hour fire rated common wall located adjacent to the linear accelerator had a gap in excess of one eighth of an inch between the meeting surfaces of the doors when closed.

Interview with maintenance representative #1 at the exit conference on September 12, 2011, between 9:00 AM and 9:15 AM, confirmed the excessive gap between the meeting surfaces of the fire rated common wall doors.

Based on observation and interview it was determined the facility failed to properly maintain exit corridor walls in fifteen of twenty one smoke compartments in this component.

Findings include:

A. Observation of corridor walls on September 9, 2011, between 08:30 AM and 3:40 PM, revealed numerous unprotected horizontal penetrations in exit corridor walls on all levels, caused by the heating, cooling and ventilation (HVAC) system.

Interview with maintenance representative #1 at the exit conference on September 12, 2011, between 9:00 AM and 9:15 AM, confirmed the presence of unprotected horizontal penetrations in exit corridor walls on all levels were caused by "open return plenums" used extensively in the construction of the original building. The facility identified that it has an acceptable Fire Safety Evaluation System (FSES) revised on September 12, 2011, addressing this issue.

Based on observation and interview it was determined the facility failed to properly maintain corridor doors in five of twenty one smoke compartments in this component.

Findings include:

A. Observation on September 9, 2011, between 9:54 AM and 2:20 PM, revealed the following corridor door deficiencies:

1. 9:54 AM - Fourth floor, Wound care center staff lounge, corridor door will not close and latch in the frame.

2. 10:10 AM - Fourth floor, room 484, corridor door held open by unauthorized door block.

3. 10:11 AM - Fourth floor, Home care administrative assistant's office corridor door held open by unauthorized door block.

4. 1:41 PM - First floor, Women's Health Center, door by scheduling held open by an unauthorized wedge.

5. 1:43 PM - First floor, Women's Health Center, door by registration held open by an unauthorized wedge.

6. 1:58 PM - First floor room C1156A, corridor door held open by an unauthorized rubber wedge.

7. 2:17 PM - First floor room C1186, corridor door held open by an unauthorized rubber wedge.

8. 2:20 PM - First floor, small office suite across from the Work center rest rooms, has two forms of latching.

Interview with maintenance representative #1 at the exit conference on September 12, 2011, between 9:00 AM and 9:15 AM, confirmed these corridor door deficiencies.

Based on observation and interview it was determined the facility failed to properly protect vertical openings in one of twenty one smoke compartments in this component.

Findings include:

A. Observation on September 9, 2011, between 9:07 AM and 9:10 AM, revealed the following deficiencies:

1. 9:07 AM - Abandoned air handler penthouse, unprotected vertical penetration in floor around electrical conduit.

2. 9:10 AM - Abandoned air handler penthouse, unprotected 2 foot by 2 foot, vertical penetration into a mechanical shaft.

Interview with maintenance representative #1 at the exit conference on September 12, 2011, between 9:00 AM and 9:15 AM, confirmed the unprotected vertical penetration deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain one smoke barrier wall affecting two of twenty one smoke compartments in this component.

Findings include:

Observation on September 9, 2011, at 1:54 PM, revealed the first floor smoke barrier located at the radiology department had an unprotected horizontal penetration around communications wires above the suspended ceiling.

Interview with maintenance representative #1 at the exit conference on September 12, 2011, between 9:00 AM and 9:15 AM, confirmed this unprotected smoke barrier penetration..

Based on observation and interview it was determined the facility failed to properly maintain smoke barrier doors in two instances affecting four of twenty one smoke compartments in this component.

Findings include:

A. Observation on September 9, 2011, between 11:00 AM and 1:55 PM, revealed the following smoke barrier door deficiencies:

1. 11:00 AM - Third floor, smoke barrier door adjacent to room 376 will not close in its frame and resist the passage of smoke.

2. 1:55 PM - First floor, smoke barrier door at radiology has two forms of latching installed.

Interview with maintenance representative #1 at the exit conference on September 12, 2011, between 9:00 AM and 9:15 AM, confirmed these smoke barrier door deficiencies.

Based on observation and interview it was determined the facility failed to properly configure hazardous areas in six of twenty one smoke compartments in this component.

Findings include:

A. Observation on September 9, 2011, between 9:16 AM and 2:15 PM, revealed the following hazardous area deficiencies:

1. 9:16 AM - Fifth floor, records room door held open with an unauthorized wedge.

2. 10:14 AM - Fourth floor, Home Care file room door lacks a required self-closing device.

3. 1:16 PM - First floor, non-sprinklered work center office/file storage room, lacks 1-hour fire rated enclosure.

4. 1:22 PM - First floor, non-sprinklered work center reception office and adjacent dead-end corridor used for file storage, lacks 1-hour fire rated enclosure.

5. 1:30 PM - First floor, Drug testing storage room door lacks a required self-closing device.

6. 1:35 PM - First floor, Women's Health Center, surgical tech supply room had two doors held open by unauthorized wedges.

7. 2:09 PM - First floor, Cancer treatment center, secretarial records room lacked a required self-closing device.

8. 2:52 PM - Basement (facility Ground floor) Environmental services storage room door was held open by a trash container filled with mop heads.

Interview with maintenance representative #1 at the exit conference on September 12, 2011, between 9:00 AM and 9:15 AM, confirmed these hazardous area deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain required exits in one of twenty one smoke compartments in this component.

Findings include:

Observation on September 12, 2011, at 8:15 AM, revealed central supply room's rear exit was blocked by a metal cart and boxes.

Interview with maintenance representative #1 at the exit conference on September 12, 2011, between 9:00 AM and 9:15 AM, confirmed this required exit was obstructed by a cart and cardboard boxes..

Based on observation and interview it was determined the facility failed to properly store medical gas cylinders in one of twenty one smoke compartments in this componentnt.

Findings include:

Observation on September 9, 2011, at 12:46 PM, revealed eight E-sized oxygen cylinders were improperly stored in the second floor same-day surgery clean storage room.

Interview with maintenance representative #1 at the exit conference on September 12, 2011, between 9:00 AM and 9:15 AM, confirmed the second floor same-day surgery clean storage room was not properly configured as a medical gas cylinder storage area.

Based on observation and interview it was determined the facility failed to properly configure occupied space in one of twenty one smoke compartments in this component.

Findings include:

Observation on September 9, 2011, at 2:50 PM, revealed a basement (facility ground floor) mechanical room had an environmental services washing machine installed in an area with insufficient head room. This mechanical area was not designed as an occupied area.

Interview with maintenance representative #1 at the exit conference on September 12, 2011, between 9:00 AM and 9:15 AM, confirmed this mechanical room was being utilized as an occupied laundry work station.

Based on observation and interview it was determined the facility failed to properly maintain the installed electrical distribution system in four of twenty one smoke compartments in this component.

Findings include:

A. Observation on September 9, 2011, between 1:10 PM and 3:15 PM, revealed the following deficiencies:

1. 1:10 PM - Second floor, same day surgery supervisors office had two surge suppressor power strips daisy chained together.

2. 2:29 PM - First floor, ACLS/CPR training room had surge suppressor power strip powering two coffee pots, a microwave oven and a refrigerator.

3. 3:13 PM - Basement (facility ground floor), Radiation Oncology unit has temporary holiday lighting in use in excess of 90 days.

4. 3:15 PM - Basement (facility ground floor), Radiation Oncology waiting area had a surge suppressor power strip powering a lamp and holiday lighting.

Interview with maintenance representative #1 at the exit conference on September 12, 2011, between 9:00 AM and 9:15 AM, confirmed these electrical distribution system deficiencies.

B. Observation on September 12, 2011, at 8:25 AM, revealed the basement (facility ground floor) Pre-Hospital services office had an unauthorized surge suppressor power strip being used to power a battery charger and a microwave oven.

Interview with maintenance representative #1 at the exit conference on September 12, 2011, between 9:00 AM and 9:15 AM, confirmed this electrical distribution system deficiency.