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Based on record review and interview, the facility failed to ensure elevator shafts were enclosed with construction with a fire resistance rating of at least one hour in 2 of 4 buildings. This deficient practice could affect any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., the public and staff elevators in the "E" building and Block wing were equipped with standard steel doors that do not bear a label indicating the fire resistive rating. Based on interview on 07/29/14 at 9:45 a.m., the Director of Engineering acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

Based on record review and interview the facility failed to ensure the travel distance from the most remote point to a smoke barrier does not exceed 200 feet in 2 of 4 buildings. This deficient practice could affect any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., the travel distance from the most remote point to a smoke barrier exceed 200 feet in Zones 2B, 4A, 5A and 1J. Based on interview on 07/29/14 at 9:45 a.m., the Director of Engineering acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

Based on record review and interview, the facility failed to ensure at least two exits with a least one exit providing a continuous path of travel to an exit discharge were provided. LSC 19.2.4.1 states not less than two exits of the types described in 19.2.2.2 through 19.2.2.10, remotely located form each other, shall be provided for each floor or fire section of the building 2 of 4 buildings. LSC 19.2.2.4 states smokeproof enclosures complying with LSC 7.2.3 shall be permitted. LSC 7.2.3.5 states every smokeproof enclosure shall discharge into a public way, into a yard or court having direct access to a public way, or into an exit passageway. Such exit passageways shall be without openings other than the entrance from the smokeproof enclosure and the door to the outside yard, court or public way. The exit passageway shall be separated from the remainder of the building by a 2 hour fire resistance rating. This deficient practice affects any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., exit stairs in the "E" building and Block wing do not discharge to the outside or through an approved exit passageway. Based on interview on 07/29/14 at 9:45 a.m., the Director of Engineering acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

Based on record review and interview, the facility failed to ensure the travel distance to an exit does not exceed 150 feet in 2 of 4 buildings. This deficient practice could affect any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., the travel distance to an exit exceeds 150 feet in Zones 1B and 1J. Based on interview on 07/29/14 at 9:45 a.m., the Director of Engineering acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

Based on record review and interview, the facility failed to ensure the width of aisles or corridors serving as exit access was at least four feet in 2 of 4 buildings. This deficient practice could affect any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., the corridor width was reduced to less than four feet in Zones 1F and 1J. Based on interview on 07/29/14 at 9:45 a.m., the Director of Engineering acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.