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A) (New 02/05/10): Based upon the FSES dated October 9, 2009, for the South Building, the East/West Building and the South Annex Building, the construction type is less than Type I and less than Type II (222) construction Although the buildings are constructed of reinforced concrete, the slab thickness between concrete beams or concrete ribs has been identified with less than a one hour fire rating. Based upon the FSES, these three buildings are Type II (000) Construction, as defined by NFPA 220 and they do not comply with 19.1.6.2.

A) (New 02/05/10) Relocated from K038:

5th Floor SCLAN Room has three doors with double cylinder dead bolt locks. At least one corridor door must b comply with 7.2.1.5 and must be identified with signage if the other two doors are locked.

(Modified 02/05/10): The double cylinder dead bolts have had thumb-turn install: however, positive latching hardware is not provided on corridor doors. For SCLAN Room 546S, W. Passage 500SW, and E C T 550S, the LSC plans do not identify whether these three rooms are a suite. The exact location of exit access corridors and corridor doors is not very clear:

1) The south door from SCLAN Rm 546S is a corridor door. Positive latching hardware (that latches automatically (with use of a key and/or other motions) when the door is pulled closed, is not provided.

2) Either the east door from E C T 550S and the north door from SCLAN Rm 546S both lack positive latching hardware, or)

the north door from Passageway 500SW is the north boundary of a suite and the door lacks positive latching hardware.

The surveyor finds a number of fire dampers that are not installed in accordance with NFPA 90A. Where the issue appears to be strictly an issue of the damper installation (including the damper location relative to the fire barrier), the deficiencies will be cited under K067.

Deficiencies with missing fire dampers at floors or shafts and deficiencies with materials used around fire dampers at floor will be cited under K020.

A) Vertical openings, including duct shafts are not enclosed or protected in accordance with 19.3.1.1 and/or NFPA 90A:

1) Corrected 08/08/08.

2) There is a 3rd Floor shaft with an access door opposite Room 3007. The shaft has two ducts that penetrate the floor above, with fire dampers. Two ducts extend into the 3rd Floor without fire dampers. Multiple ducts penetrate the floor below (there is a large void open to the ceiling below) without fire dampers. Although the access door for the shaft is fire rated, the shaft stops at the 3rd Floor ceiling and is drywalled only on one side. The area below is open to the 3rd Floor ceiling cavity. The surveyor notes that the area below may be outside roof area. The surveyor is still not able to determine how the floor assembly (2 hour floor) and the lack of a shaft enclosure complies with NFPA 90A.

9/25/09: The above item was not corrected in accordance with the last submitted PoC.

3) Corrected 02/05/10

4) Corrected 08/08/08.

5) Corrected 02/05/10

6) 2nd Floor Mechanical Room: multiple duct penetrations through the floor below and the floor above do not appear to be installed in fire rated floor assemblies. UL ratings and/or tested assemblies or details were not available. Many of these locations involve the installation of fire dampers that may or may not be installed in the plane of the fire barrier (see also K067): (text deleted 02/05/20 - see original survey for full text)

The parameters for the FSES used in the PoC have been confirmed by a surveyor on 02/05/10. This tag will remain open for this item until all other deficiencies in Building 03 are corrected in accordance with the FSES and/or PoC.

7) (Modified 02/05/10): 2nd Floor Mechanical Room: damper # 06612: the access panel appears to be too low for inspection and cleaning. Confirm testing, service and cleaning from the Fire Damper Schedule.

a) Deleted 02/05/10

b) The gray duct wraps around the
exit passageway and penetrates the 2nd
floor slab twice. (EF-42). Only one
of the two duct penetrations has
a fire damper and/or fire damper access
panel.

8) 2nd Floor Mechanical Room: some duct penetrations lack fire dampers in accordance with NFPA 90A. Example: stainless steel duct for EF 7.

02/06/10: The above item was not corrected in accordance with the last submitted PoC. Why does this duct and similar duct penetrations not have fire dampers?

9) Deleted - 02/05/10

10) (New 02/05/10): from 2nd Floor Mechanical Room observations:

a) Fire damper/smoke damper 06585 - where is the damper access panel

b) There is a duct penetration through the floor south of FD 06585 - where is the fire damper and where is the fire damper access panel.

c) FD 06588 - that fire damper access pane is too small. Demonstrate how this fire damper has been tested, serviced and maintained from the Fire Damper Schedule (history of maintenance).

d) FD 06593 - northing on the motor assembly and within the damper assembly that is visible identifies this device as a fire damper. Who says that it is a fire damper?

e) FD/SD 04886 - the access panel is too far from the damper assembly.

f) FD 04884 and 04886 - could not find or observe that a fire damper is installed.

11) Smoke control system - see K067

A). By direct observation the surveyor finds during fire alarm testing, that activation of a smoke detector on first floor immediately on the corridor side of the door to stairwell #1 enables what appears to be a stairwell fan pressurization system.

09/25/09: The surveyor observes that the above referenced system has been partially removed from this stair. However, a response to the following was not provided:

12/12/08: Please provide more information.... the system was physically removed and openings close with fire rated materials (where required)?? The connections to the fire alarm were terminated and fire alarm programing modified?? Fans were removed or tagged?

1) The surveyor notes that the abandoned fan is located behind an unrated access panel in the stair at a landing 1 1/2 levels above the stair discharge.




20224


B). Modified 12/12/08: Ground floor - Stair #5 - Surveyor observed a continuous unprotected path of travel to the exterior which does not comply with 7.7.1 and/or 7.7.2.

The discharge path at the Ground Floor has been modified; however, the RJA drawings do not identify an exit passageway and they do not indicate how the stair discharge for the above stair complies with 7.7.1 or 7.7.2.

1. This stair appears to be the only exit stair
serving Radiation, Xray, Pulmonary and
the floors above. The stair discharges
interior to the ground floor. The plans
or PoC do not clearly indicate how the
stair discharge complies with 7.7.1

2. Corrected 02/05/10 but dependent up responses above

C). Modified 12/12/08: Ground floor and First floor- Stair #4 - Surveyor observed a continuous unprotected path of travel to the exterior which does not comply with 7.7.1 or 7.7.2:

1. This stair appears to discharge interior into a 2-hour passageway. This exit passageway is not identified as such on any plans. An exit passageway is not identified on the RJA Drawings and no two hour fire walls or fire doors are identified on the RJA Drawings.

2. Corrected 08/08/08.

3. Corrected 12/12/08

4. Corrected 12/12/08

5. Corrected 12/12/08

6. (New 12/12/08) Unless this stair can comply with 7.7.2 and does not require a discharge through an exit passageway, the stair discharge is directed through the stair enclosure and discharge for Stair # 3. By combining the exit discharges, the stairs no longer constitute remote exits.

A) (Modified 02/05/10): Doors in means of egress have locking devices that do not comply with 7.2.1.5 or 7.2.1.6. Although specific examples are cited under each building the surveyors find that there is a pattern of doors with exit signs above them that are locked and that do release immediately and/or do not have the delayed egress provisions of 7.2.1.6.

Based upon continued deficiencies with locking devices in multiple buildings the surveyor finds that the provider does not have a systematic program: to locate every such device, evaluate each location for compliance and implement corrective actions where necessary. See K038 of Building 03 and Building 01 below.

This citation includes all doors with magnetic locking devices, including but not limited to.

02/05/10: The above deficiency was not corrected in accordance with the last submitted PoC. The provider has a list of locations; however, many of the doors observed on 02/05/10 still do not comply with 7.2.1.5 or 7.2.1.6. Adequate interim life safety measures for this condition were not found

1) Corrected 02/05/10 - 12798

a) Corrected 02/05/10 - 12798

b. Corrected 02/05/10 - 12798

2) Corrected 9/24/09

3) Corrected 9/24/09

4) (New 02/05/10) - multiple pairs of doors with exit signs above the doors, in the 1st Floor Imaging Center and nearby, have magnetic locking devices that do not comply with the above requirements.

A). (Modified 09/25/09) The Second floor Mechanical room referred to as the OB/ICU mechanical room or as 2-West Mechanical room is a three story space. Access to this room is gained through Stair #8 located on the First floor. The stair is open to the Mechanical Room and is the third floor level of this open space. Surveyor observed that this room (greater than 1000 s.f.). Stair 8 is not an exit (it does not comply with 7.7.1), it is only an exit access. The previous reference to 19.2.5.2 is for patient areas. The PoC does not indicate how this mechanical area complies with 7.12.2 or 42.2.4, 42.2.5 and 42.2.6.

The PoC does not include the submittal of a project to IDPH in accordance with the Department's rules for projects. The corrective action that was implemented does not comply; access to the roof does not include any exit path off of the roof. The PoC does not indicate why two means of egress out of this space are not required.

A). Ground Floor, 95th Street Cafe, East end conference rooms - East wall between conference rooms and dishwashing and cart storage constitutes a 2-hour barrier wall (according to the facility Life Safety Plan). Surveyor observed the length of the wall between the above listed areas does not continue to the under side of the floor deck above to comply with 8.2.3.1.

B). Ground Floor, 95th Street Cafe, East end conference rooms - East wall between conference rooms and dishwashing and cart storage constitutes a 2-hour barrier wall (according to the facility Life Safety Plan). Surveyor observed that no dampers were present in any of the ducts which penetrated a portion of this wall to comply with 9.2.1 and NFPA 90A.

C). Ground Floor, 95th Street Cafe, East end conference rooms - East wall between conference rooms and dishwashing and cart storage constitutes a 2-hour barrier wall (according to the facility Life Safety Plan). Surveyor observed that not all door openings were protected to comply with 8.2.3.2.3.1 for the required fire rating. Surveyor noted several doors which contained a U.L. rated design label for a 20 minutes.

D). Corrected 02/04/10 - 12798

E). Corrected 02/04/10 - 12798

The surveyors will need to confirm that each location cited is not identified on plans, before this item can be cleared.

A) Deleted 02/05/10

1) Corrected 12/11/08

2) Corrected 12/11/08

3) Deleted 02/05/10

4) (Modified 02/05/10): The recent Auditorium/IC/OR Project and the facility drawings for this project have not been coordinated with the Life Safety Master Plan:

3rd Floor Mens Staff Locker Room: Stair Enclosure - there is a hole through the wall of the stair enclosure, above the ceiling (south wall of stair).

A) The surveyors find that the fire alarm systems for multiple buildings are not installed and maintained in accordance with NFPA 72:

1) (Modified 12/12/08): The surveyors find that the fire alarm systems for multiple building are designed to activate globally and notify occupants globally (activation in one location closes doors, activates other functions and activation is seen and heard audible through out the building). However, fire alarm strobe devices active globally in some of the buildings and activated only on the floor that initiated fire alarm activation, in other buildings. The activation of strobes in the East/West/ South/Annex Building by example, activate only on the floor of incident (only flash on the floor where the fire alarm is activated). The strobes do not activate globally in conjunction with all other fire alarm devices in this same building. The activation of visual devices (strobes) in the East/West/ South/Annex Building does not comply with 9.6.3.7 of NFPA 101.

2) (Modified 12/12/08): Fire alarm strobes (multiple floors and multiple buildings) are not synchronized in accordance with 4-4.4.1.1 (4) (NFPA 72).

02/05/10: update the PoC for the above two items as needed. The above two items were be confirmed only when both items have been fully corrected.

3) Although fire alarm deficiencies are also cited building, the surveyors note a pattern of lack of compliance. Activation of the fire alarm is not audible and visible in all portions of the building in accordance with NFPA 70:

a) Corrected 9/25/09
b) Corrected 9/25/09
c) Corrected 02/04/10 - 12798
d) Corrected 02/04/10 - 12798
e) Corrected 02/04/10 - 12798
f) Corrected 02/04/10 - 12798

4) a) Corrected 02/04/10 - 12798
b) Corrected 02/04/10 - 12798

Examples include but are not limited to:

i) Corrected 9/25/09
ii) Corrected 02/04/10 - 12798
iii) Corrected 9/25/09
iv) Corrected 9/25/09




12797

B. Corrected 02/04/10 - 12798
C. Deleted 9/25/09
D. Deleted 9/25/09
E. Corrected 02/04/10 - 12798
F. Corrected 02/04/10 - 12798
G. Deleted 9/25/09
H. Corrected 02/04/10 - 12798
I. Corrected 02/04/10 - 12798

A) The sprinkler system is not installed and maintained in accordance with NFPA 13/25:

1) 2nd Floor Storage Space next to Service Elevator 34: This room is sprinklered. Some of the sprinkler heads are obstructed by storage that is closer than 18" below the sprinkler heads. In other parts of the room the sprinkler protection is compromised by storage above the sprinkler heads.

02/04/10: There is a deep storage space under a low beam along the entire north wall of this space. Sprinkler protection under the beam is not provided.

2) Corrected 08/08/08.

A. Based upon random observation the surveyor finds that HVAC systems do not comply with NFPA 90A and/or ASHRAE:

1. Corrected 02/05/10

2. Corrected 12/11/08

3. Fire dampers are installed at fire barriers but they are not installed in accordance with the manufacturer's requirements and/or U L Testing Requirements for the installation of fire dampers:

a. Fire dampers are installed with
intumescent caulk around the damper
and/or around the retaining angles:

1) Corrected 12/12/08

2) Corrected 12/12/08

3) Deleted 02/05/10

b. Fire dampers and/or combination
fire/smoke dampers are not installed
within the plane of the fire barrier.
Dampers are installed well beyond the
plane of the fire barrier and do not
comply with the damper manufacturer's
requirements and/or NFPA 90A:

1) Text deleted - 02/05/10

1.5) Also, one or more of these dampers
was heavily coated with lint or dust
indicating the lack of maintenance.

2) Text deleted - 02/05/10

3) Text deleted - 02/05/10

See original survey for deleted text. All of item "b" above (except for cleaning and maintenance of fire dampers) is part of an FSES that has been revised. This tag will remain open until all corrections have been completed in accordance with the PoC and/or FSES.

B. Modified 02/05/10: The surveyor observed smoke dampers, above ceiling at random locations where the was not smoke barrier or any kind of barrier that would require a smoke damper. Hospital personnel present were not able to explain why these smoke dampers were located where they were found. The surveyor is not able to determine what these smoke dampers are installed for and/or that they are not part of a smoke control system.

02/05/10: The surveyor notes that duct penetrations in the 2nd Floor Mechanical Room sometimes have fire dampers only, immediately next to ducts with combination fire/smoke dampers.

Other examples include: Corridor near Room 4075 and the north end of the corridor that links the 4th Floor of Surgery to the Main Building.

The surveyor is not able to determine that an engineered smoke control system was installed in this building and that it was part of the life safety requirements of this building. The surveyor finds no evidence to indicate that this smoke control system has been tested and maintained in accordance with 9.3.1 of NFPA 101 and/or NFPA 92A.

The PoC lacks a final correction date.

A) (New 02/05/10): A portable electric heater was observed on the countertop (Ground Floor corridor wall opening) of the Flower Delivery Area in the corridor near Stair # 7.

A) (New 02/05/10): Chute Room 034E: This chute discharge from is not installed and maitained in accordance with NFPA 82.

1) Both that trash chute and linen chute for this building discharge into the same receiving room at the Ground Floor.

2) The room is sprinklered; the sprinkler system is compromised by missing ceilings.

3) The trash chute and the cart were so full that the bagged trash was backed up into the chute. The door to the chute has a fusible link but was blocked open by teh buidlng up of bagged waste.

4) The Linen chute and the cart were so full that the bagged linen was backed up into the chute. The door to the chute has a fusible link but was blocked open by thr buidl up of soiled linen

5) There was water and debris on the floor of this room.

A) Based upon random observation, in multiple patient corridors on multiple floors, the surveyor finds that exit access corridors are obstructed by beds, computers on wheels, equipment, linen storage carts, etc.

1) Corrected 12/11/08

2) Corrected 02/05/10

3) Corrected 12/11/08

4) Corrected 12/11/08

5) Corrected 09/25/09

6) (New 02/05/10): 3rd Floor ASHU Unit - the exit access corridor near the nurse's station was partially obstructed by a repair cart, a computer and a bed. The corridor near Room 3644 as also obstructed by a bed. Equipment stands in the corridor near Room 3639 also obstructed the exit access corridor.

A) (New 12/12/08): The surveyor observed a number of large waste carts, bi-hazard waste carts and other types of carts, typically in exit access corridors and in open elevator lobbies that are part of an identified means of egress (multiple buildings and multiple floors). In some cases waste materials were stacked to the ceiling.

B) (New 12/12/08): The surveyor observed one or more enclosed elevator foyers where waste materials were held in the foyer, including bio-hazard waste. The foyers were not open to an exit access corridor. The surveyor observed at the signage on the elevators in these foyers designated them as "service and patient" elevators. The surveyor observed one such foyer with waste storage, where staff attempted to use the elevator for patient movement.

For those enclosed elevator foyers that are separated from all other portions of the building by one hour barriers and that are used as waste holding areas:

1) Patient movement through such hazardous areas is prohibited by NFPA 101.

2) Waste holding areas are required to comply as soiled holding spaces with negative air pressure relative to surrounding areas. The surveyor observed not evidence of negative area in the areas identified.

9/25/09: Item A and B will be monitored on multiple surveys for compliance before it will be cleared.

02/05/10: Building 04, East/West. The Service Elevator Lobbies on Floors 3, 5, 7 and 8 are open to the exit access corridors. Although bio-hazard materials and soiled material were not observed in these areas, the lobbies were still observed with stored items, equipment and empty boxes.

A) (New 02/05/10): Ground Floor Loading Dock on the east side of the East/West/South Building. This loading dock has a caged area for medical gas storage. Based on observation some of the tanks were not secured in accordance with NFPA 99 and 6'-0" of clearance is not maintained between all oxidizers and combustible materials.

A) Corrected 09/25/09

B) 1. Corrected 08/08/08.

C) Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Interim life safety measures for Building 03 were found to be not adequate.

1) Through regular inspection rounds and/or through increased fire drills, the provider has failed to detect and abate the conditions cited under K038 for locking devices on doors with exit signs.

2) Through regular inspection rounds, through increased fire drills, through in-service training, the provider has failed to detect and abate the conditions cited under K018.

A) (New 02/05/10): 3rd Floor Surgical Unit: O R 16 (3344) a large black cabinet was parked in a niche in the corridor, blocking access to the Line Isolation Monitor Panel.