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A) The Southeast Stair discharges to the outside at the Lower Level and then requires travel up a zig-zig concrete ramp. The ramp is partially protected with a fabric structure and has lighting mounted above the ramp. The surveyor was not able to determine how emergency lighting is provided along this exterior path.

A) The provider lacks a comprehensive set of Life Safety Master Plans that accurately identify the following:

Smoke Barriers (w/ ratings), the size of smoke compartments, Fire Barriers w/ ratings, locations of vertical shafts along with the fire ratings, locations of all exit enclosures, including the fire ratings and including all exit passageways, the size and location of all suites, etc.

1) The 8 1/2 x 11 drawings that were available from the provided some of the above information but not all of it. The surveyors found from random observation that the information on these 8 1/2 x 11 drawings were not entirely accurate.

The size of smoke compartments was not provided

The locations of some fire barriers, some shaft enclosures, some suites and some rooms was not accurate. Location includes:

a) Corrected 02/04/09

b) 3rd floor PICU, sliding doors do not contain latching hardware, suite not defined.
UPDATE 1/21/10: The facilities Architect indicated that the sliding doors are to the ante room and are not the corridor wall. The PICU is not a suite and therefore not defined. The surveyor has requested revised drawings which define the corridor walls and corridor doors. The drawings need to clearly indicate any/all exit passageways.

c) Corrected 02/04/09

Locations of exit passageways were not identified.

B) Cleared 1/21/10: The FSES (see K029) is no longer required since the storage has been removed from the patient rooms.

A) Corrected 1/21/10

B) The existing sprinkler protection is compromised by missing ceiling tiles (example: Lab 204).

A) Based upon observation and personnel interview, the surveyors find that multiple elevators do not have automatic recall in accordance with ANSI A17.3

1) The provider identified three elevators (elevators 3, 4 & 5) that have been modified to comply with the automatic recall requirements of ANSI A17.3. The provider indicated that one of these three elevators did not comply with the shunt-trip requirements of A17.3 and that all other elevators in the Hospital do not comply with the recall requirements of ANSI A17.3..

2) Corrected 02/04/09