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A) From random observations, the surveyors find that vertical openings are not enclosed and protected in accordance with 19.3.1.1 and NFPA 90A. Some shafts but not all shafts are identified on the 2009 Life Safety Code Plans. Also, some shafts are identified with no enclosure indicated; some shafts are identified with non-combustible shaft enclosure and some are identified with two hour fire rated enclosures. In too many locations to list, the surveyors observed shaft enclosures that were not enclosed in fire rated enclosures. General deficiencies include but are not limited to:

* Shafts are open to the ceiling cavities of adjacent spaces.

* Shafts are not enclosed in fire rated construction

* Shafts have multiple penetrations or voids that are not sealed or they are sealed with unrated materials

* Shafts have access panels that are not fire rated and not self closing

* Many shafts are inaccessible and cannot be inspected.

* See K067

Locations include but are not limited to:

1) (Modified 10/22/09) 1963 Building Basement Machine Room: this space is open and unseparated from one or more vertical shafts. The space lacks fire dampers where required by NFPA 90A. See also K067

2) Pavilion Basement Mechanical Room: this space is open and unseparated from one or more vertical shafts. The space lacks fire dampers where required by NFPA 90A and the uses in this mechanical room conflict with requirements of NFPA 90A. See also K067

3) Basement Level - Former Incinerator Room: 10/21/09 - moved to K029

4) Loading Dock: The Loading Dock Platform has two freight elevators. One freight elevator has an opening in the wall above the elevator door. The door has some type of damper. The damper was closed. The provider was not able to identify what this open was, whether the damper was a fire damper and why it was closed. The elevator shaft appears to communicate to several floors and extends up into the 2nd Floor.

4.5) Corrected 10/21/09

5) 1st Floor Dietary: There is a shaft behind the Janitor's Closet in the Southeast Corner of Dietary and behind the Southeast Stair. The shaft does not penetrate the 2nd Floor. Confirm that the shaft does not penetrate the 1st Floor (into the Basement Level) No access into the shaft is provided.

The shaft has one hole above the ceiling of the Janitor's Closet, that is not sealed for fire rated construction.

6) The Northwest Stair at the 1st Floor has shafts on three sides of the stair. These shafts have several sleeves or penetrations that are not sealed with fire rated materials. The shafts are open to the ceiling cavity of an adjacent locker room (surveyor notes indicate at Northeast corner of shaft - but this location may not be accurate).

a) One shaft has only one layer of drywall and multiple voids, above the ceiling in the locker room. The surveyor noted that the pipe chase at this location continues up as a vertical opening.

7) 1st Floor Pantry 1-038: There is a vertical duct above the ceiling, next to the elevator shaft. The duct lacks a fire rated enclosure or lacks a fire damper at the penetration through the floor above. This area is not accessible at the 2nd Floor.

8) 1st Floor near Entrance C (next to Emergency Department) There is a large duct shaft (T1207)that is shown with a two hour fire rated enclosure. Two ducts penetrate this shaft above the ceiling. Fire dampers and fire damper access panels were not found.

9) 1st Floor Shaft at the south end of the Emergency Department (T1159) and at the north end of Radiation Oncology: Multiple ducts penetrate the shaft above the ceiling. Fire dampers and fire damper access panels were not found. At least multiple duct penetrations have a label that indicates that the fire damper was removed.

10) 1st Floor (New) CT Scan Suite

a) Multiple penetrations through the floor
are not sealed with fire rated materials

b) There is a large duct shaft (T1216) that
is identified with a two hour fire rated
enclosure. Multiple duct penetrations on
two sides of the shaft, lack fire dampers
(one duct says the fire damper was
removed).

c) No access through the ceiling is possible
on the south side of the shaft (Existing
X-ray Room). Similar conditions are
expected by the surveyor.

d) The shaft wall is missing at the east side
of the shaft, above the ceiling. The shaft
and the Basement Mechanical Room
below are open to the ceiling cavity of
this 1st Floor Suite.

Interim measures including a constant
fire watch is required until Item d above
is abated.

11. 2nd Floor Electrical Closet (T2034): The duct penetration into the adjacent shaft has a label on the access panel that indicates that the fire damper was removed (actually it was disabled) on 12/32/02. The surveyor also notes that the disabled fire damper was not installed in the plane of the fire barrier.

12. 2nd Floor: There is a duct shaft (T2201) in a corner next to Elevator 1 and 2; one or more duct penetrations above the ceiling lack fire dampers.

13. 2nd Floor: There is a duct shaft (T2196) in a corner next to Elevator 3 and 4; one or more duct penetrations above the ceiling lack fire dampers.

14. 2nd Floor: There are two shafts in the Pharmacy Area, one each next to Elevator 2 and 4: It was not possible to inspect above ceilings in this area. Any duct that penetrates this shaft will not have a fire damper and other penetrations are likely to be unsealed.

15. 2nd Floor Uni-sex Bathroom (possible Toilet T2155?) The adjacent shaft is shown on plans without any rating. The shaft wall above the ceiling has a large hole in it that is stuffed with Visqueen. A duct cuts longitudinally through the edge of the shaft wall. How is the shaft wall maintained as a fire rated barrier is not evident. Confirm location - may be another bathroom.

16. 2nd Floor next to the Service Elevators: There is a Kitchen Exhaust Duct Shaft (T2119) that was identified by the provider. The plans do not show this shaft with a fire rated enclosure. No inspection is possible. Without a fire rated shaft enclosure, the kitchen exhaust duct constitutes a severe and unnecessary hazard to the occupants.

18. 2nd Floor Cardiac Rehab Gym - adjacent elevator loading dock shaft: access panel/door is not self closing.

19. 2nd Floor shaft west of the Service Elevators: Access was available on one site only and the plans are not accurate for this area. Two duct penetrations above the ceiling lacked fire dampers - label says that they were removed.

20. 2nd Floor Electrical Closet (T2136), across from Elevator # 5: There is a hole into a shaft above the ceiling of this space.

21. 2nd Floor Elevator Foyer in front of Elevator 6: access panel provides access above the ceiling - there is a large void in the shaft to the east.

22. 2nd Floor Audiology: At the east wall there is a round duct that penetrates the floor above- no fire damper was found.

K020 ALL - Modified 5/12/10: The last submitted PoC identifies an FSES to be submitted for the above items by 4/16/10. An FSES has not been submitted. Further, an FSES by date and by preparer (to identify it as a specific document) is not identified in the PoC and has not been submitted with a PoC.

23. (New 5/12/10): Lower Level SPD Commode storage space (space with cement board ceiling immediately adjacent and below the Linen Chute) The space is not separated from the Linen Chute and/or Linen Chute Room by two hour fire barriers. The linen chute shaft is open to the ceiling cavities.





20224


A) The surveyor finds a number of fire dampers that are not installed in accordance with NFPA 90A. The surveyor was not able to get into many locations where fire dampers might be confirmed because many of the rooms contained gypsum board ceilings which lacked access panels (and the dampers were not accessible).

1) A duct penetration through a designated 2 hour fire resistant floor assemblies were observed that, due to the lack of fire damper, allowed the passage of smoke and fire between floor levels. Surveyor observed the duct extending through only one floor. This condition does not comply with NFPA 90A 1999 3-3.2. Location observed:

Eleventh floor, South West wing,
Nourishment room located across the
corridor from the 3 bank, Service
Elevators. A flexible duct penetration
through the floor above, located in the far left
corner of the room above the finished
ceiling, lacked a fire damper.

2) Three ducts penetrate at least 7 floors without being enclosed in a 2 hour fire rated shaft enclosure to comply with NFPA 90A 1999 3-3.4.1. Surveyor observed these ducts within a telecommunications closet. This "closet" is currently part of a ventilation shaft on each floor but does not comply with NFPA 90A for a 2-hour enclosure. The conditions cited are as follows:

a. These ducts originate in the 13th floor
penthouse and terminate above the
ceiling of the 6th floor. Surveyor did not
fire the refernced ducts are enclosed in
a continuous fire rated shaft enclosure.
Therefore the room is part of the shaft
enclosure on each floor and is deficient
on multiple floors.

b. Example: The communication closet
titled Telecom # T12042 - 12th floor (on
the life safety plan) includes the ducts
from the 13th floor mechanical room.
This shaft enclosure does not provide a
continuous fire rated separation due to
the following:

i) The walls of the closet could not be
determined to provide a U.L. listed
2-hour fire rated wall assembly.

ii) The walls of the closet were not
continuously sealed against the
passage of smoke and fire.

iii) The doors to the closet do not
provide a continuous separation for a
shaft enclosure due to the following:

iv) The doors are not self closing.

v) The doors lack a fire resistant U.L.
listed label for a 2-hour rated shaft
enclosure.

c. The 6th floor duct exiting the closet
enclosure lacks a damper installation to
comply with NFPA 90A 1999 3-3.4.4.

d. Similar conditions are expected on other
floors at the same location.


C.) A duct penetration through a designated 2 hour fire resistant shaft was observed that, due to the lack of fire damper, allowed the passage of smoke and fire between floor levels. This condition does not comply with NFPA 90A 1999 3-3.2. This condition was observed for this shaft on each floor level. Locations observed include but are not limited to:

1. Eleventh floor, shaft T 11065 adjacent to
Patient room # 1130 (room numbers
according to facility life safety plan).

2. This same "shaft" is incomplete.
Example: 9th floor. Surveyor viewed
into the "shaft" enclosure (as indicated
on the facility life safety floor plan) and
observed vertical pipe runs. This "shaft"
is open to the adjacent occupiable
spaces via the wardrobe closets.

It could not be
determined due to lack of access,
whether the pipes are sealed at each
floor penetration to comply with
8.2.3.2.4,or if the ductwork contains fire
dampers to comply with NFPA 90A.

D) Multiple floors and multiple locations: Shafts are identified on the 2009 Life Safety Code Plans as: "noncombustible shaft enclosure (example: T9039)," some shafts are identified with two hour enclosures (Example: T9139) while others are indicated as "shafts" (with no enclosure identified - example: 9th floor T9066 & T9068).

Example location 9th Floor - shaft T9026 (according to facility life safety plans) The "central core" contains large duct "shafts" on each floor level. Some shafts are identified on the facility life safety drawings as a "noncombustible shaft enclosure" while others are indicated as "shafts (example 9th floor T9068). All indications for shafts lack a 2-hour fire resistant rating to comply with 19.3.1.1.

1. There are no fire dampers in the walls where ducts leave these shafts.

2. There are no access doors to allow an inspection of these shafts. The surveyor is not able to determine how these shafts comply with NFPA 90A and why fire dampers are not provided at designated shaft walls.

E) 13th floor Exhaust Fan room for the South East toilet rooms- Surveyor observed duct and pipe penetrations through a designated 2- hour fire rated shaft wall installation (according to the facility Life Safety Plan). The Exhaust fan room is considered part of the vertical shaft installation but does not comply with the requirements for vertical separations due to the following:

1. The designated shaft wall was
incomplete and did not extend tight to
the underside of the roof ceiling
structure above.

2. The ducts lacked damper installations.

3. The pipes were not sealed against smoke
and fire.

Modified 5/12/10: The last submitted PoC identifies an FSES to be submitted for the above items by 4/16/10. An FSES has not been submitted. Further, an FSES by date and by preparer (to identify it as a specific document) is not identified in the PoC and has not been submitted with a PoC.

A) Exit stairs are not configured and constructed to comply with 7.7.1 and/or 7.7.2: There are four required exit stairs from the Basement Level. The same four exit stairs are the only exit stairs that serve the 5th Floor and above (Northeast Stair, Southwest Stair, Center Core Stair and Southeast Stair).

1) The Northeast Stair and the Center Core Stair do not discharge as a protected path to the outside in accordance with 7.7.1. These two stairs only comply with 7.7.2 if the other two stairs comply with 7.7.1. The Southeast Stair complies with 7.7.1.

The Southwest Stair discharges into a 1st Floor exit passageway that does not comply with 7.2.6 and 7.7.1.

a) The "exit passageway" for the Southwest
Stair is not identified specifically on the
Life Safety Plans as an exit passageway.
It is shown as a corridor space with two
hour or four hours barriers that extend
from the discharge doors to a four hour
Chicago vestibule north of Dietary. The
exit passageway does not comply as a
two hour fire rated exit passageway.

b) Multiple ducts penetrate the above
referenced two hour and four hour fire
barriers, above ceilings. While some
duct penetrations may have fire
dampers, many duct penetration lack fire
dampers and/or fire damper access
panels. One or more ducts have access
panels that indicate that the fire
dampers were removed. (see also K067)

c) Corrected 10/22/09

d) See also K020, K044 and K067

2) The southwest stair isa required exit for the 12 story bed tower. The exit changes direction and transfers through a vestibule at the 2nd Floor and then continues as an exit stair, discharging at the 1st Floor. This 2nd Floor vestibule can only be an exit passageway. The vestibule does not comply with 7.2.6 as an exit passageway:

a) It is not identified on plans as an exit
passageway.

b) Two or more ducts penetrate the
designated/required two hour walls of
this vestibule and do not have fire
dampers in accordance with NFPA 90A

c) The stair door at the top of the stair run
from the 2nd Floor to the 1st Floor is
locked against re-entry. The stair door
from the stair above is locked against re
entry in the 2nd Floor Vestibule and the
2nd Floor door to the Vestibule is locked
against re-entry. The only path provided
from the 2nd Floor Vestibule is down
and out. This condition does not meet
the intent of 7.1.5.2 and/or City of
Chicago requirements.

A) The 1st Floor Dining Room and Cafeteria Servery The Servery was permitted to have a 2nd exit path into the Kitchen as long as the Kitchen and aisle/corridor leading from the Servery into the Kitchen does not become a hazards area.

5/12/10: Combustible storage was found in Room T1091 (foyer with bag-in-box soda system). The provider lacks effective means to prevent this space from being used for storage.


20224


A. Based on random observation during the survey walk through the surveyor noted a designated suite (as shown on the facility life safety plan) which does not comply with 19.2.5.6 for the size of a patient sleeping room.

Location observed: Fifth Floor ICU suite (approx 5,461 s.f..) exceeds the square footage allowed by the Life Safety Code for a patient sleeping room. See also K038.

Modified 5/12/10: The last submitted PoC identifies an FSES to be submitted for the above items by 4/16/10. An FSES has not been submitted. Further, an FSES by date and by preparer (to identify it as a specific document) is not identified in the PoC and has not been submitted with a PoC.

Modified 5/12/10: The last submitted PoC identifies Life Safety Plans that were to be available by 3/31/10. As of 5/12/10 such plans were not available. The small scale plans pulled from the draft copy of an FSES are intended to identify the zones used in the FSES; they are not prepared and intended to serve as fully documented life safety code plans.

A) The Southwest Stair discharges to the outside on the west side of the building. Means of egress lighting at the discharge outside was not found by the surveyor.


20224


A. The finding is that an exterior egress path was observed that is not provided with lighting, on emergency power, so that the failure of one fixture (bulb) will not leave the area in darkness, to comply with 19.2.8.

Location observed: 12th floor exit door from Library to exterior balcony leading to the North Wing exit stair enclosure. Surveyor noted that there was no exterior lighting provided at the exit discharge door from the Library or at the stair entrance door. The facility representative was unable to verify that the remaining exterior lights were on emergency power.

A) (5/12/10 New): The provider lacks effective means to confirm that corrective actions have been completed in accordance with the submitted PoC, by the dates identified in the PoC. The provider failed to revise the PoC, in writting and submit modified form 2567 with revised correction dates, prior to the dates that expired. Based on the survey of 5/12/10, there were a significant number of items taht should have been corrected that were not.

B) (5/12/10 New): The provider was not able to identify where and how a number of items had been corrected. Accurate plans with rated barriers, etc were not available and the provider was unable to find room numbers for rooms that corrective actions were made. The rooms numbers used in the citations were furnished by the provider on previous surveys.

A) Based upon document review and personnel interviews, the surveyors find that the sprinkler systems are not tested, serviced and maintained in accordance with NFPA 25.

1) Two of two fire pumps

a. Corrected 5/12/10

b. Documentation of annual testing of the
fire pumps, including testing on
emergency power in accordance with 5-
3.3.4 (NFPA 25 - 1999), was not available.

5/12/10 - documentation was incomplete

c. 5/12/10 deleted - refer to K063

2) Building sprinkler system (The building is fully sprinklered except where indicated in K056):

a. Documentation of quarterly flow testing
was incomplete. 5/12/10: The quarterly
report of 2/23/10, identifies locations:
that were skipped, devices that were
not accessible, and devices that are not
wired to the fire alarm. Also, a tamper
switch on a pump discharge failed the
test and was identified as "to be
corrected ASAP."

b. The documentation of annual testing,
service and maintenance is incomplete:

Corrected 5/12/10: exercise of valves

Corrected 10-22-09: Lube of valves

10/22/09: Documentation still does not
indicate that all gauges are calibrated or
replaced every five years and the
documentation does not include last date
that this was done.

5/12/10 - The above item has not been
corrected in accordance with the last
submitted PoC

Documentation does not indicate that a
complete inspect was conducted and the
annual inspection failed to find and abate
the deficiencies cited under K056.

Documentation (dated 1/13/09) for an
annual sprinkler inspection indicates four
pages of deficiencies that have not been
corrected during the past two years

(New 10/22/09): The documentation
of testing and maintenance that was
available on site fails to address the
deficiencies statements above.

10/22/09: The sprinkler documentation of 1/13/09 and 4/29/09 contains numerous asterisks and references an addendum for each report. The provider was unable to explain the asterisks on each report and failed to provide the addendum, after repeated requests from the surveyor.

5/12/10: The PoC lacks an item-by-item response for each of the above deficiencies.

3) Modified 5/12/10: Dry Pipe sprinkler systems - Loading Dock: The documentation dated 2/23/10, fails to identify the annual "trip" test and/or the full trip test this is required every three years. The date of the last full trip test is not documented

a) Corrected 10/22/09

b) Corrected 10/22/09

4) Four Pre-action Dry Pipe systems - multiple systems - identify each:

a) The provider lacks documentation for
each system that indicates an annual
inspection of each system was conducted
including the internal inspections that are
required under 9-4.3.1.3 and 9-4.3.1.4.

5/12/10:
The forms dated 4/29/09 are more than
one year old. The forms are not
completely filled out and some required
testing is marked "NA".

b) Documentation testing in accordance
with 9-4.3. is not
available for each system.

c) Documentation of testing of the fire
alarm components for each system is not
available.

The provider failed to correct the above
items in accordance with the last
submitted PoC.

5) Anti-freeze systems:

Annual testing indicates that three of three
anti-freeze systems have been tested for the
last two years and the specific gravity for
each
system tests well above the expected winter
ambient temperatures for each of the three
systems.

There is no indication that this was corrected.
There is no documentation that indicates that
the entire system (each system) has been
inspected and that some or all of each
system
is not damaged by freezing.

10/22/09: The provider failed to correct the above item in accordance with the last submitted PoC.

5/12/10: The provider failed to correct the above item in accordance with the last submitted PoC.

6) Corrected 5/12/10

A) Based on direct observation, the facility failed to provide:

Remote alarm annunciators for 2 of 2 fire pumps at a point of constant attendance. NFPA 20, 1999, 7-4.7

(Note: Annunciators are provided at the central plant operators control room/office which is not constantly attended.)

10/22/09: The provider lacks documentation of testing of four monitoring points for two or two fire pumps. The surveyor attempted to confirm compliance with the last submitted PoC by activating a fire pump and observing any monitoring in the Security Office. No monitoring was found.

5/12/10: the above item was not corrected in accordance with the last submitted PoC.

A) Based upon direct observation, the surveyors find that the kitchen hood suppression systems, are not installed, tested and maintained in accordance with NFPA 13 - 1999. NFPA, 96 - 1998 and the hood suppression system manufacturer's specifications.

1) (Modified 10/22/09): 1st Floor Main Kitchen: A Gaylord, water based, grease extraction system and misting head hood suppression system is installed in multiple hoods in the Kitchen. The Provider has the manufacturer's installation and maintenance specifications on site.

a) The main cooking line has been
modified. Cooking appliances have
been removed and new appliances have
been installed. The hood system and
hood suppression system have not been
modified for the new appliance

i) *Seven suppression nozzles are
obstructed or and install in such a
way as to provide no protection.
Multiple ranges have nozzles
that are still partially
obstructed by a
overhang shelf and are not installed
in accordance with the suppression
manufacturer's specifications.

ii) Corrected 5/12/10

iii) Deleted 10/22/09

2) The above referenced cooking line, hood system and hood suppression system (1st Floor Main Kitchen) are not tested, serviced and maintained, semi-annually in accordance with NFPA 13 and NFPA 96:

a) The Kitchen Hood and Hood Suppression
System were not re-certified when the
appliance under the hood changed.

b) Testing documentation from an outside
contractor dated 3/11/09 indicated that
system was operational and the "nozzles
are correctly positioned. The nozzles
were not installed in accordance with the
suppression manufacturer's
specifications.

c) Testing, service and maintenance
documentation was incomplete:

i) Documentation for semi-annual
inspection, testing and maintenance was
not found. The most recent report for
2010 was not available on site.

ii) The documentation does not identify
testing that was conducted to confirm
that the fuel sources for ALL appliances
under the hood shut off upon activation
of the system.

5/12/10: The last available onsite
documentation, indicates
that the are only gas fired appliances
under the Kitchen Hoods and they have
been tested and perform in accordance
with the referenced standards. However,
there is a tilt skillet with hood
suppression above it. This appliance is
electrically fueled. There is no
evidence indicates that: there is an
automatic shut off for this appliance, that
it has been tested and that it compliance
with NFPA 13/17/96.

iii) Duct cleaning - Corrected 10/22/09

iv) No documentation is provided to
indicate whether this system complies
with U L 300 in accordance with
7-2.2 of NFPA 96 - 1998

v) The documentation does not
indicate that activation of the system actives
the building fire alarm system.

vi) Corrected 5/12/10

05/12/10: Corrections were not completed in accordance with the last submitted PoC. The provider terminated interim life safety measures without correcting the deficiencies cited.

a) Semi-annual testing, maintenance and inspection in accordance with NFPA 96 was not performed semi annually.

b) Corrected 5/12/10

The above citations will not be cleared until till full documentation of two semi-annual inspections (that indicate full compliance) are found. The current arrangement of sprinkler nozzles above the ranges (partially obstructed by shelves) does not comply with NFPA 13 - 1999 (5-6.5.1.2). The surveyor recognizes that the misting head sprinkler suppression system is a specialized system however, the provider lacks evidence of how this system complies and why the sprinkler heads referenced are not obstructed.

3) The Kitchen or Servery Cooking areas were recently modified to include that addition of an outside make up air fan. The provider indicates that this system has not worked properly since it was installed. The provider lacks documentation of testing that indicates that the existing systems provide adequate make up (replacement air) in accordance with 5-3 of NFPA 96.

An air balance report for this system is not available on site.

5/12/10: the above item was not corrected in accordance with the last submitted PoC.


4) (New 10/22/09): The 1st Floor Cafeteria Serving Area has three Kitchen Hoods with ANSUL Suppression Systems. These three systems are not tested, serviced and maintained in accordance with NFPA 17A and NFPA 96.

a) Corrected 5/12/10

b) Three separate, individual, ANSUL Systems are provided. Which hood is served by each ANSUL system is not clearly identified. 5/12/10: The hoods and pull stations are clearly identified; however, the three ANSUL systems lack clear identification as to which hood is served.

c) Deleted 5/12/10

d) (Modified 5/12/10): Gas fire equipment is installed at two hoods (one w/ four fryers and one with a char grill and a flat grill). The third hood has electrically fueled hot plates. The location of the automatic gas shut off valve for the four fryers is not known. 5/12/10: There was no PoC for this item and the provider still is unable to identify the automatic gas shut off valve for two hoods with gas fired appliances.

Based upon the semi-annual testing documentation dated 5/12/10, two of three hoods lack automatic fuel shut off (gas) upon activation of the hood suppression system for each hood in accordance with NFPA 17A and NFPA 96.

The surveyor required the following on 5/12/10 - The appliances under the deficient hoods may not be used until the deficiencies are corrected, tested and documented by a third party qualified technician, indicating the each system complies with NFPA 17A and NFPA 96.

e) Corrected 5/12/10

f) (New 5/12/10): Two of three kitchen hoods in the 1st Floor Servery had grease filters that were improperly re-installed. The provider removes the filters for cleaning but failed to re-install the filters for two hoods such that there were no gaps, open joints, etc. that allow grease to by-pass the filters.

5) (Modified 5/12/10) Given the lack of documentation of semi annual maintenance and testing (Repeat Deficiency) and given the failure to implement and complete corrective actions in accordance with the last submitted PoC, enhanced interim life safety measures are required until all items are corrected.

5/12/10: The large ABC extinguisher in the main Kitchen in inappropriate for the type of fires that occur in a kitchen area and does not comply with NFPA 10.



14416


A) Corrected 5/12/10

A) From random observation, the surveyors find that trash and line chutes do not comply with NFPA 82:

1) The Basement Level Linen Chute Discharge Room

a) Corrected 5/12/10

b) Corrected 5/12/10

c) Six ducts penetrate the walls of the
Linen Chute Discharge Room. Two of
the ducts appear to penetrate the trash
chute enclosure. Six of six ducts lack
fire dampers in accordance with
NFPA 90

d) Deleted 10/22/09

2) (Modified 5/12/10): the Basement Trash Chute Discharge Room

a) The cart under the chute and the room
was so fully that the fire rated chute
door could not close. This was
observed in the afternoon on several
days in spite of the audible alarm that
calls attention to this deficiency

The above item was uncorrected on
5/12/10. The provider lacks effective
means to prevent re-occurrence.

b) The walls that enclose this space are
required two hour barriers (and are
identified as such on plans). Three
duct penetrations lack fire dampers in
accordance with NFPA 90A. One
duct has a label on the access door
that indicates that the fire damper
was removed. (note; the above
item may be located in a different
room that indicated above)

3) Corrected 10/22/09

4) 2nd Floor Trash Chute Room: The chute door was found open and the latch was taped; the chute door is not self closing and positive latching.

5) 2nd Floor Audiology has an access panel that opens to an Linen Chute area. The door to the Linen Chute was not self closing and positive latching.

A) Not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. For example furnishings and equipment were observed stored in 8'-0" wide exit access corridors. These objects obstruct paths of egress which does not comply with 19.2.3.3. and 7.1.10.2.2. Locations observed:

1. 3rd floor corridor surrounding the
Surgery suite - numerous carts,
equipment, containers of combustible
materials covered in plastic were
observed for the length of the corridors.

2. 4th floor C-Section area - contained
furniture and equipment, including a
couch.

Modified 5/12/10: The last submitted PoC identifies an FSES to be submitted for the above items by 4/16/10. An FSES has not been submitted. Further, an FSES by date and by preparer (to identify it as a specific document) is not identified in the PoC and has not been submitted with a PoC.

Modified 5/12/10: The last submitted PoC identifies Life Safety Plans that were to be available by 3/31/10. As of 5/12/10 such plans were not available. The small scale plans pulled from the draft copy of an FSES are intended to identify the zones used in the FSES; they are not prepared and intended to serve as fully documented life safety code plans.


B) The clear width of required exit access corridors were observed to be obstructed by wall mounted units that were open and unattended. Locations observed: Surveyor noted the following on numerous Medical-Surgical floors:

1. Wall mounted charting stations with
hydraulic arms. Items are observed
"stored" on these stations, maintaining
the writing surface in the horizontal
"open" position. This impedes the
required 8'-0" width of the exit access
corridors.

2. Wall mounted isolation cabinets with
hydraulic arms. Items are observed
"stored" on these cabinets maintaining
the units in the horizontal "open"
position. This impedes the required
8'-0" width of the exit access corridors.

C) Corrected 5/12/10

D) (New 5/12/10): A podium was placed in the 1st Floor exit access corridor just north of the Gift Shop, obstructing a portion of the required corridor width.

A) (Modified 5/12/10): Based upon observation the Dietary elevator lacks automatic recall in accordance with ANSI A17.3.

This item was not corrected in accordance with the last submitted PoC.

A) 1) (New 5/12/10): The surveyor finds that (under any condition including fire alarm activation) the elevator doors on one or both sides of the elevator staff open indefinitely on any floor unless a button is pushed inside the car to close the doors.

B) Corrected 5/12/10

C) (New 10/22/09): The dietary elevator pit lacks a sprinkler head in the pit in accordance with NFPA 13.

5/12/10: the above item was not corrected in accordance with the last submitted PoC.