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A. Based on random observation uses in corridors do not comply with the exceptions under 19.3.6.1 Exception #1(a). The surveyor observed patient care areas that are open to the exit access corridors. Example locations include:

1. 2002 addition Second floor Recovery, Day Surgery Prep and Stage I Recovery.

2. 1977 addition First floor, Radiology Department, numerous use spaces open to exit access corridors.

3. CORRECTED 02/10/2010


B. The Facility representative during staff interview was unable to verify that these areas constitute a suite to comply with 19.2.5.2. Other similar locations observed:

1. Pain Clinic, Physical Therapy, and Occupational therapy. These areas all contained habitable room locations which lacked an exit access door leading directly to an exit access corridor to comply with 19.2.5.1.

A. CORRECTED 02/10/2010

1. CORRECTED 02/10/2010

a. CORRECTED 02/10/2010


B. CORRECTED 02/10/2010

1. CORRECTED 02/10/2010


C. Pipe penetration through 2 hour fire floors were observed throughout the facility which are not sealed with a U.L. listed design assembly to protect against the passage of fire to comply with 8.2.3.2.4.1. Example locations observed:

1. CORRECTED 02/09/2010

2. 1957 addition First floor Generator room PVC pipe penetrates the 2-hour floor above.

3. 1977 addition Ground floor Boiler room PVC pipe penetrates the 2-hour floor above.

4. 1977 addition Second floor Pathology room PVC pipe penetrates the 2-hour floor above.

5. CORRECTED 02/10/2010

A. Based on random observation during the survey walk-through, not all suites are constructed or configured in accordance with 19.2.5.
Location observed: The Second Floor Recovery Area(s), Day Surgery Recovery/Prep area were observed to house holding bays that are not separated from the exit access corridor. The unit is not indicated on the facility's Life Safety Master Plans as constituting a suite. Numerous patient care areas are not directly connected to an exit access corridor, however the facility's Life Safety Floor Plans do not indicate these areas as constituting suites. Example locations refer to K-Tag 017 for habitable rooms not directly connected to exit access corridors.

1. The unit constitutes a suite which is in excess of the area permitted by 19.2.5.7.

OR

2. The holding bays are open to an exit access corridor which does not comply with 19.3.6.1.

A. The provider lacks a comprehensive Life Safety Code Master Plan for each floor. The information provided for this survey and was not accurate as a Life Safety Code Master Plan.

The plans provided with colored lines indicating life safety features:

1. Exit Passageways were not indicated, however, the facility representative stated that certain areas were indeed exit passageways, however, during the walk through they were found to be deficient.

2. Fire barriers are identified with a red line. What type of fire barriers is not clear. The fire ratings for these barriers are not identified. Some of the barriers are clearly combination fire/smoke barriers but they are not identified as such. Other barriers enclose, shafts, exits and/or hazardous areas; however, not enough information is provided to evaluate such locations for compliance.

3. Smoke barriers are not identified as such. The fire ratings for each smoke barrier are not identified.

4. The size and boundary of each smoke compartment is not identified on plan.

5. The provider has no information identifying the locations, size and boundaries of suites. Travel distances in suites could not be evaluated. All areas have been evaluated in this survey as if there are no suites and all areas have exit access corridors, until such time that accurate information is provided. The surveyors expect to find additional deficiencies (for corridors) if accurate information regarding suites is not provided.

The surveyor finds that the provider cannot comply with 19.1.1.3 without the information identified above.

A. Based on direct observation, the facility failed to provide automatic smoke detection at the fire alarm control panel. Locations include but not limited to the Laboratory Waiting Room.
(NFPA 72, 1999, 1-5.6)

B. By direct observation the surveyor finds numerous smoke detectors located within 3 feet of supply air diffusers. (NFPA 72, 1999, 2-3.5.1).




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C. Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed to comply with 19.3.4. During a test of the facility fire alarm system the following was observed

1. CORRECTED 02/10/2010


2 Fire alarm strobes (where three or more devices are visible) are not synchronized in accordance with NFPA 72 and the Illinois Accessibility Code. This includes the Second and Third MedSurg Floors.

Based on direct observation and document review, the facility failed to provide:

A. A remote alarm annunciator for the fire pump at a point of constant attendance. (NFPA 20, 1999, 7-4.7)

B. Indication that the annual fire pump flow test was conducted under emergency power. (NFPA 25, 1998, 5-3.3.4)

C. Indication that alarm conditions were simulated at the time of the annual fire pump test. (NFPA 25, 1998, 5-3.3.3)

A. By document review and staff interview, evidence was not provided for the 4 year inspection and maintenance of fire and smoke dampers. NFPA 90A, 1999, 3-4.7

Based on direct observation and staff interview, the facility failed to provide:

A. Remote alarm annunciator for three of three emergency generators at a constantly attended work station. NFPA 99, 1999, 3-4.1.1.15 (b)

B. Remote manual emergency stop stations for three of three emergency generators.
(NFPA 110, 1999, 3-5.5.6)


C. Three required branches of the essential electrical system (life safety, critical & equipment) for the 1913 building and additions, 1939, 1957 & 1963. (Staff indicated there is one transfer switch for the from the generator located on the first floor of the 1957 addition, with a connected load less than 150 kVA)


D. A separate 2 hour enclosure for the emergency generator located in the 1957 addition. (NFPA 5-2.1)


E. Fire sprinkler protection for the emergency generator enclosure located within the boiler room of the 1977 building.


F. CORRECTED 02/10/2010

A. By direct observation the surveyor finds all elevators are not provided with the required Firefighter's Service elevator recall.