HospitalInspections.org

A) (Modified 04/16/10): The provider still lacks accurate information that demonstrates compliance with 19.3.7.1. The life safety plans available still are not accurate. (see K048)

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

Modified 04/16/10: The provider lacks accurate information that identifies the boundaries of each smoke compartment, and the fire ratings for barriers that separate smoke compartments. See K048.

1) Modified 04/16/10: see K025

a) Deleted 4/16/10

b) Deleted 4/16/10 - see K048

c) See K048

d) Corrected 4/16/10


2) Deleted 04/16/10

B) Deleted - not used

C) (New 11/18/09): The one story 1995 addition that includes the 1st Floor Main Entrance Lobby and the 1st Floor Emergency Department constitutes new construction that required a complying smoke barrier. A smoke barrier that includes the above space is not identified on the Life Safety Code Master Plan in accordance with 18.3.7.3.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

D) (New 11/18/09): The 2004 Project that includes the 1st Floor Cardiac Cath Lab Suite constitutes new construction that required a complying smoke barrier. A smoke barrier that includes the above space is not identified on the Life Safety Code Master Plan in accordance with 18.3.7.3.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

E) (New 11/18/09): The 1st Floor West Wing has a continuous barrier that includes smoke dampers at duct penetration. Barring evidence to indicate otherwise, the surveyor finds that this barrier is an existing smoke barrier that defines a smoke compartment in the West Wing. This smoke barrier may not be diminished (4.6.7). The smoke barrier is not identified on the Life Safety Code Master Plan in accordance with 18.3.7.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

F) Corrected 04/16/10
1) Corrected 04/16/10
2) Deleted 04/16/10
G) Corrected 04/16/10 .
H) Deleted 04/16/10

A) Based upon random observation the surveyor finds that designated fire barriers are not installed and maintained in accordance with Chapter 8 of NFPA 101 - 2000:

1) Corrected 04/16/10

2) Corrected 11/18/09

3) Modified 11/18/09: The provider indicated that the 2nd Floor SNF unit on 2 West is separated from the rest of the building by a two hour fire barrier (not necessarily required). The surveyor notes that 2 West is separated from the rest of the floor by a smoke barrier (rating unknown).

a) Deleted 04/16/10

b) The Life Safety Code Master Plans will need to be revised to accurately show complying smoke and fire barriers for the 2nd Floor (based upon the PoC for the Hospital and the PoC for the SNF Unit). See also K025

c) (04/16/10 - Modified from above): The current Life Safety Master Plans identify a smoke barrier at 2 South. The designated smoke barrier is deficient; the south wall of the Beauty Shop is missing above the ceiling. See also K025

If the smoke barrier remains on the Life Safety Master Plans, correction will be required. If a complying two hour fire smoke barrier is installed, as required by a Long Term Care Surveyor, at 2 North and the 2 South smoke barrier is deleted from the plans, correction at 2 South will not be required. The Life Safety Plans will need to be revised to show the revised smoke compartment sizes and the reviews locations of fire and smoke barriers.

4) (Modified 04/16/10) The single door behind the 2nd Floor Center Nurse's Station, to the SNF activity room has a magnetic hold open device. The wall is a required two hour fire barrier and possibly a required smoke barrier.

The door hold open lacks local smoke detection in accordance with 7.2.1.8. This was not corrected in accordance with the last submitted PoC. A smoke detector has not been installed within five feet of the door.

A) Based upon random observation from testing and the lack of documentation, the surveyor finds that some sprinkler control valves are not supervised electronically and many are not tested at least annually in accordance with NFPA 25.

1) The annual sprinkler system documentation of testing (and/or any other testing performed) does not provide an list item-by-item list of each tamper switch tested along with a pass/fail analysis. A list of the total number of devices tested vs the total number existing was also not available. The forms are not filled out completely and the documentation is incomplete. The surveyor could not determine what has been tested.

2) Corrected 11/18/09

3) Corrected 11/18/09

A) Based upon random observation, the surveyor finds that HVAC systems, fire dampers, smoke dampers, etc. are not installed in accordance with NFPA 90A:

1) Corrected 11/18/09

2) Corrected 11/18/09

3) Corrected 04/16/10




26665


A) Based on random observation, the surveyor found access panels in ductwork which contained fire protection devices (fire dampers, smoke dampers, duct detectors, etc.) that were not identified with letters 1/2" high identifying the type of fire protection device with-in as required by NFPA 90A 1999 2-3.4.2. Locations include but are not limited to;

1) Corrected 11/18/09
2) Corrected 11/18/09.
3) Corrected 04/16/10

B) Based on observation, the surveyor found locations where air intakes were installed less than 3' above the roof surface, air filters not sealed to prevent bypass and filter banks installed with no device to monitor pressure drop across the filters as required by NFPA 90A and ASHRAE Chapter 7.

4/16/10: the PoC does not appear to address the filter deficiencies and monitoring deficiencies cites above.

1) Corrected 11/18/09
2) Corrected 11/18/09
3) Corrected 11/18/09
4) Corrected 11/18/09
5) Corrected 04/16/10

6) The second floor mechanical room AHU's air intakes were observed to be less than 3' above the roof surface.

04/16/10: The above item was not corrected in accordance with the last submitted PoC. A 01/08/10 final correction date was identified in the PoC.

A) Based on random observation, the surveyor found components of the linen and trash chutes which does not comply with NFPA 82 requirements for self -closing and latching.

1) The first floor trash chute door in the corridor does not latch as required by 3-2.4.2.

2) Corrected 04/16/10

3) The lower level trash collection room chute door does not latch as required by 3-2.4.2.

4) The lower level linen collection room chute door does not latch as required by 3-2.4.2.

5) The lower level trash collection room chute door was tied open with a wire which prohibits self-closing.

6) The lower level linen collection room chute door was tied open with a wire which prohibits self-closing.

A) From observation, the surveyors find that oxygen storage tanks are stored (place in rack and not in locations for immediate use) in rooms with combustibles and do not comply with NFPA 99. In rooms with sprinkler protection oxygen is stored closer than five feet to combustible. In rooms without sprinkler protection oxygen is stored closer than 20'-0" to combustibles. Locations include but are not limited to:

1) 4th Floor ICU Storage Room - not corrected 11/18/09 4/16/10 - not shown to surveyor.

2) Corrected 11/18/09

3) Corrected 04/16/10

A) The surveyors find that the facility has an outside bulk oxygen storage system that does not comply with NFPA 99 and NFPA 50:

1) Corrected 11/18/09

2) The nearby recycling shed and the combustibles within are not at least 25 feet from the oxygen tanks.

04/16/10 - revise the correction date for the above item.

B) From random observation the surveyors find that medical gas systems are not installed and maintained in accordance with NFPA 99 - 1999.

1) Corrected 11/18/09

2) Corrected 11/18/09

3) All floors with medical gas vacuum outlets in patient rooms or recovery spaces. Medical gas shut off valves were not found. The provider was not able identify the location of the vacuum riser shut off valves for each floor. Locations include but are not limited to:

a) 5th Floor Stage II Recovery spaces.

b) 4 East Bronchoscopy Room and 4 East
patient rooms.

c) Patient rooms of 3 North

4/16/10: The above items were not corrected in accordance with the last submitted PoC. A revised PoC either indicating what corrections are required or indicating why correction is not required, was not submitted prior to the correction date indicated in the PoC. The year of installation for each existing system is required to confirm that correction is not required.

4) Corrected 11/18/09

5) 5th Floor Surgical Unit.

a) Corrected 4/16/10

b) Pre-op and the Post operative
Recovery Room have medical air,
oxygen and vacuum medical gas vacuum
systems. The vacuum system lacks area
shut off valves.

c) O R # 7 and O R # 8 have have medical
gas vacuum system but lack room, area
or floor shut off valves.

d) Corrected 11/18/09

4/16/10: The above items were not corrected in accordance with the last submitted PoC. A revised PoC either indicating what corrections are required or indicating why correction is not required, was not submitted prior to the correction date indicated in the PoC. The year of installation for each existing system is required to confirm that correction is not required.

A) Based upon the limited information available and based upon random observation, the surveyors find that smoke barriers have duct penetrations that lack smoke dampers or combination fire smoke dampers in compliance with 19.3.7.3. The surveyors also note that the building is only partially sprinklered and does not comply with exception # 2 for sprinkler protection except for locations entirely within 5 East and 4 East)

1) Deleted 11/18/09

2) Deleted 11/18/09

3) Corrected 04/16/10

4) The designated two hour barrier at the entrance to 2 East has one or more duct penetrations with no combination fire/smoke dampers. This barrier is not identified on the Life Safety Code Plan as a two hour fire barrier, as a smoke barrier or both. One or both may be required.

5) Corrected 04/16/10

The surveyors find that above citations are examples only and not a comprehensive list. The surveyors also find that provider lacks a complete list of all fire dampers and smoke dampers with the locations identified.

04/16/10: The surveyor finds that some locations have smoke dampers and/or combination fire/smoke dampers with coil-op designs and a motor on top of the duct, while other dampers are pivoting type dampers with a pivot or axle running vertically through duct and a motor on top. The surveyor does not find documentation that shows that these fire dampers are tested and maintained in accordance with NFPA 90A.

Also the surveyor finds that the damper motor assembly is recess into the fire wall on top of the duct. This creates a void in the fire barrier of smoke damper in the barrier above the duct. The surveyor finds no information on site to show how this condition is smoke tight and/or fire rated.

A) Based upon random observation and document review that surveyors find that seven of seven elevators (all elevators except for two freight elevators) are not installed and/or tested in accordance with ANSI A17.3.

1) The provider lacks documentation demonstrating that every elevator is tested for automatic fireman's recall (floor and alternate floor) for every elevator, annually.

04/16/10: The above item was not corrected in accordance with the last submitted PoC.

2) (Modified 11/18/09): Elevator # 4 lacks automatic and manual recall in accordance with ANSI A17.3.

04/16/10: The above item was not corrected in accordance with the last submitted PoC. The PoC was not modified and resubmitted with a new correction date before the correction date identified in the last submitted PoC. The PoC for the above item msut providxe a detailed phasing schedule, with dates, that identifies how it will be brought into compliance or) it is to be disabled and walled off immeidately.

3) (New 11/18/07): Based upon direct observation the surveyor finds that Elevator 1, 2 and 3 lacks automatic recall to a designated alternate floor in accordance with ANSI A17.3. Activation of a 1st Floor Elevator Lobby smoke detect results in recall of the elevator to the 1st Floor with the doors opening to the floor or fire origin.

04/16/10: The above item was not corrected in accordance with the last submitted PoC. The PoC was not modified and resubmitted with a new correction date before the correction date identified in the last submitted PoC.