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The facility did not ensure that the common wall of the non-conforming building was a fire barrier having at least a two-hour fire resistance rating constructed of materials required for the addition as required by the referenced LSC.
On 02/09/10 at 01:10 PM the surveyor, accompanied by the Maintenance Technician, observed that the building separation between Milne Pavilion and Luscomb Building at the 1st floor, had voids around the penetrations that were not protected with materials having a 2-hour fire rating-as required by the referenced, Life Safety Code; i.e. black iron sprinkler piping, copper heating & cooling pipes and rigid, electrical conduit with no fire stopping from new construction.

The facility did not ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch sold-bonded core wood, capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke.

On 02/09/10 at 09:30 AM and times throughout the day, the surveyor, accompanied by the Director of Facilities, observed that the corridor doors for the 1st and 2nd floor bariatric rooms and exam rooms had two leaf doors that had a gap between the leafs in excess of ? inch and not resistant to the passage of smoke and fire from the corridor.

The facility did not ensure that a fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72.

On 02/11/10 at 10:00 AM, The surveyor was not provided with documentation by the Director of Facilities that all fire alarms are tested as required. A documentation review identified that the Burgess Building Duct Smoke Detectors, manual pull stations, and smoke detectors were not tested and maintained in accordance with NFPA 72 i.e. older fire alarm initiating devices not being maintained or removed.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

1. On 02/11/10 at 2:30 PM, the surveyor was not provided with documentation by the Director of Facilities Support Services to indicate that flow tests had been conducted on the standpipe systems throughout the facility, as required every 5 (five) years by NFPA 25.

2. On 01/27/04 at 1:30 PM, the surveyor was not provided with documentation by the Director of Facilities to indicate that the deficiencies identified for the Milne Building dry pipe valve had been corrected and re trip tested as required by NFPA 13 an NFPA 25 i.e. 2 minutes 31 seconds for valve to trip and water to reach the inspectors test connection.

The facility did not ensure that the facilities air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems as required by the referenced LSC.

On 02/10/10 at 10:00 AM, The surveyor was not provided with documentation by the Director of Facilities that all deficiencies identified on the 12/2005 fire damper inspection had been corrected, and that the fire alarm documentation from 12/18/09 & 06/16/09 inspection from Simplex Grinnell failed to identify if smoke dampers activate upon activation of the fire alarm and/or smoke detector for the smoke zones they cover as required in NFPA 90A 3-4.7 & NFPA 72.

The facility did not ensure that nonflammable medical gas systems and equipment used for the administration of inhalation therapy and for resuscitative purposes was in compliance with NFPA 99: Heath Care Facilities.

On 02/08/10 & 02/09/10 at 09:30 AM and at times throughout the days of survey, the surveyor, accompanied by the Director of Facilities observed that the facility was storing liquid oxygen portable units on Rubbermaid wheeled carts in corridors throughout all patient unit corridors and not within a ventilated oxygen storage room as required; i.e. while volume of liquid oxygen was permissible, storage in the exit access corridor & finish of cart is not.

The facility did not ensure that fume hoods were in accordance with NFPA 99 " Health Care Facilities " Chapter 5, Section 4.3 & 6.2.

On 02/11/10 at 2:30 PM, the surveyor was not provided with documentation by the Director of Facilities Support Services to indicate that the facilities fume hood is inspected annually as required in NFPA 99, and as part of the facilities preventive maintenance program (last inspection date: 01/09-due 01/10).

The facility did not ensure that Flammable and combustible liquids are used from and stored in approved containers in accordance with NFPA 30, Flammable and Combustible Liquids Code, and NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals. Storage cabinets for flammable and combustible liquids are constructed in accordance with NFPA 30, Flammable and Combustible Liquids Code, NFPA 99.

On 02/09/10 at 11:00AM, the surveyor, accompanied by the Director of Facilities observed that facilities contracted lab service was utilizing wood frame/laminate veneer cabinets with labeling indicating that they were approved flammable liquid storage cabinets. Subsequent to this observation the Director of Facilities was unable to provide documentation that these were in fact listed and/or approved flammable liquid storage cabinets.

The facility did not ensure that where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service as require by the referenced LSC.

On 02/10/10 at 11:00 AM, The surveyor, accompanied by the Director of Facilities that the fire alarm system initiating circuit for the Milne building sprinkler system was disabled and had been for at least 24 hours; i.e. sprinkler work done the day before and alarm switches never restored.