HospitalInspections.org

A. Based on review of the Life Safety Plans dated 10/09/09, based on random observation during the survey of February 5 through 8, 2013 and based on personnel interview including the Director of Engineering, the Director of Safety and the Director of Corporate Facilities the surveyor finds that portions of two buildings do not comply with 19.1.6.2.

Findings include.

1. Stair 7 is a two story stair in the 400 building that is not an exit. The stair is part of the one story (with Basement) portion of the 400 Building that is identified as Type I construction. The stair has a unrated monolithic ceiling with unrated access panels. The stair has unprotected steel (roof structure) above. This unprotected roof structure is not compatible with the designated construction type for the building and does not comply with 19.1.6.2.

2. The Emergency Room/Imaging one story addition is Type II (000) construction. The adjacent 1st Floor Lab is part of the 5 story, 400 building to the north. The 400 Building is identified as Type I (332) construction; however, a continuous two hour fire barrier is not identified separating all portions of the building with Type II (000) construction from the Type 1 Building. This reduces the construction type of the 400 Building to Type II (000) construction. The 400 building therefore does not comply with 19.1.6.2.

3. The provider identified a portion of the 1st Floor as Nuclear Medicine. The surveyor was not able to identify which building this space is located; However, the surveyor observed fire-proofed steel above the ceiling in Nuclear Medicine and observed unprotected steel in the corridor south of this space. The surveyor did not find a two hour fire barrier between these differing construction types.

4. 400 Building that is identified as Type I construction. The Basement Level Gift Shop Storage has two structural beams at the end of the room that have missing fire-proofing.

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A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed Valentine Day decorations in the 5th Floor ICU that include combustible paper hanging from ceilings and and paper decorations on walls. The surveyor did not find that the decorations observed were deficient. However, the surveyor also observed seasonal decorative lighting on an extension cord. The surveyor inquired whether the facility has a written seasonal decoration policy. The provider indicated that they did not have a written seasonal decoration policy.

The provider lacks written guide lines to control compliance with 19.3.3.2 for temporary interior finishes and 19.7.5.4 for decorations.

Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that areas that are open to exit access corridors do not comply with 19.3.6.1 of NFPA 101 - 2000.

Findings include:

1. The 1st Floor Central Waiting area is a very large waiting area on both sides of a corridor. It includes a cafe food serving area and multiple seating aeras. It is sprinklered throughout. The areas open to the corridor are not supervised 24/7 and the smoke detection installed does not cover every part of the area open to the corridor in accordance with 19.3.6.1, exception # 1 and NFPA 72.

A. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the Interconnect Wing on Floors 2 through 5 link the 350 Building to the 400 Building and are used for inpatient movment. Although the provider identifies these wings as business occupancies, the surveyor finds that they are health care occupancies because patients are moved in beds through the wings.

1. Each floor has continuous storage closets on one side of the corridor. Each closet door has a dead-bolt lock that is not positive or automatic latching in accordance with 19.2.6.2.

Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds vertical openings are not protected in accordance with 8.2 of NFPA 101

Findings include:

1. The Basement Mechanical Room for the 400 Building has a vertical shaft that penetrates three or four floors. The shaft has an insulated duct inside. The shaft may be an air intake shaft. The shaft does not comply with 8.2:

a. The shaft does not appear on the Life Safety Plans as a fire rated shaft enclosure.

b. The shaft enclosure is used for storage; this does not comply with NFPA 90A.

c. The roof of the shaft appears to be wood/lumber (construction that is not compatible with the construction type identified for the 400 Building).

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed doors with hold open devices do not comply with 19.2.2.2.6 and 7.2.1.8: Findings include:

1. Clean Utility Room A540 is large enough to be a hazardous area. The corridor door to the room has a magnetic hold open device but lacks smoke detection within five feet of the door.

2. 5th Floor pair of fire doors between the 350 Building and the East Building at the north connection. The fire doors took to much time to close to latch upon activation of the fire alarm system and at least one of the doors did not latch.

Based on observations of hazardous areas the facility failed to properly separate combustible stored materials from building occupants. The separation between hazardous areas and the means of egress failed to meet with the requirements of NFPA 101, (2000), Section 39.3.2.1 and 8.4.1.1. This deficient practice would allow a fire to spread without proper fire separation and affect all occupants in the smoke zone.


Findings include:

A. On 2/7/13, 5th floor, Medical Records Room, during the walk through of the facility with the Director of Engineering, the room was found to have a high combustible fuel load of open paper files, cardboard boxes in a room not sprinkler protected. The door and walls to the Medical Records Room are deficient because:

1. The door to the room did not have an automatic door closer. (8.4.1.3 and 7.2.1.8)
2. The door was not a 3/4 hour fire rated with appropriately listed hardware (8.4.1.3)
3. A 1-hour rated enclosure could not be verified (8.2)

B. On 2/7/13, 4th floor, Cardiac Rehab, during the walk through of the facility with the Director of Engineering, it was observed that twelve small oxygen tanks were stored along the wall in the means of egress. The storage of the tanks and separation from combustibles did not meet with NFPA 99, 8.3.1.11.2(c)(1). The means of egress is being used for storage, and is not maintained free and clear of obstructions.

C. On 2/7/13, 4th floor, Stair S15, during the walk through of the facility with the Director of Engineering, it was observed that the vestibule outside the stair enclosure, contains a large soiled linen cart in the means of egress. The cart holds three bags; each bag has a 32 gallon capacity, making this a hazardous condition and does not meet with the requirements of NFPA 101, 8.4.

E. On 2/7/13, 3rd floor, during the walk through of the facility with the Director of Engineering, it was observed that the waiting area contains an abandoned optometrist office, which is separated from the waiting room by frosted glass panels. The room is currently being used for general storage and does not comply with the requirements for a one hour fire rated enclosure under NFPA 101, 39.3.2.1 and 8.4

F. On 2/7/13, 3rd floor, during the walk through of the facility with the Director of Engineering, it was observed that the reception area contains, sliding racks of open files. The general storage of the files is not separated from the waiting area and exit route or protected in accordance with Section 8.4.

A. Based on observation on February 7, 2013, with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that exit enclosures are not installed and maintained to provide a continuous, safe path to public way in accordance with Chapter 7 of NFPA 101 - 2000.

1. Five story, exit Stair S10 discharges into a designated 1st Floor, two hour enclosed, exit passageway. The exit passageway does not comply with 7.1.3.2.1, 7.1.3.2.2,and 7.2.6 of NFPA 101.

a. The exit passageway has a monolithic
ceiling with fire rated access panels.
The access panels are not self closing.

b. The fire doors from the CDU into the
exit passageway does not latch.

c. A wood pallet was left in the exit
passageway.

2. Stair S10 at the Basement Level does not comply with 7.1.3.2.1 of NFPA 101:

a. There is a large pump recessed into the
stair floor at the Basement Level.

b. There is a 16" x 16" metal box on the
stair wall at the intermediate landing
between the Basement and 1st Floor.
The provider did not know what the box
was and/or how it is permitted in the
stair enclosure.

3. Stair S5 is a required exit stair for the Basement of the 400 Building. The stair door at this level does not close to latch.

Based on observations, the facility failed to provide stairs and exit components having a fire resistance rating of at least two hour. The exit components are to be arranged to provide a path of escape, and to provide protection against fire or smoke from other parts of the building. NFPA 101, 39.2.2.3 and 7.2.2.

Findings include:

1. On 2/7/13, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that the exit stair (Stair S14) off of the 5th Floor elevator lobby does not comply with Chapter 7 of NFPA 101. The stairwell landing contains a door to a small room which contains a water heater. Doors opens into a normally unoccupied room and is not permitted to open into a rated exit stair per NFPA 101, Section 7.1.3.2(b) and 7.2.2.5.3.

2. On 2/7/13, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that exit stair (S14) is required to be a 2 hour rated enclosure based on NFPA 101, 39.3.1.1 and 8.2.5.4(1). The stair enclsoure wall(s) to roof/deck connection were observed not to be sealed with a UL fire rated product. This condition was observed on all floors for this stairwell.

3. On 2/7/13, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that exit stair (S15) is required to be a 2 hour rated enclosure based on NFPA 101, 39.3.1.1 and 8.2.5.4(1). The wall to roof/deck connection was observed not to be sealed with a UL fire rated product. This condition was observed on all floors for this stairwell

4. On 2/7/13, 4th floor, during the walk through of the facility with the Director of Engineering, it was observed that Stair S14 has stair doors that swins into the stairwell at the stair landing, obstructing the landing. The distance between the guard rail and the edge of the door provides an 8 " clearance. The current arrangement restricts anyone from the upper floor from proceeding down the stairs during an evacuation. The stair does not meet with NFPA 101, 7.2.2.3.2 or provide an unobstructed path of egress. This condition was observed on Floors 2 through 4.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed that the means of egress to a public way is not maintained in accordance with Chapter 7 of NFPA 101.

Findings include:

1. The a pair of cross corridor doors near Room A326 have an exit sign above the doors. The doors do not swing in the indicated direction of exit travel in accordance with 7.2.1.4.2.

2. 2nd Floor - Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the 2nd Floor of the 350 Building has a 50 foot dead end corridor near Room A227. There is no exit sign at the north end of the corridor

a. The corridor terminates at a pair of doors that extend into a vacant suite. The signs on the doors indicate " no admittance " .

b. The vacant suite is used for some unenclosed storage.

c. The suite is not supervised 24/7 and cannot serve as the exit path from a corridor The suite does not currently comply with the rules for corridors or suites.

d. Many of the plumbing fixtures have trap seals that have evaporated. This constitutes a potential infection control and life safety hazard. The surveyors found not evidence of Life Safety Interim Measures. See K130.

3. 2nd Floor Interconnect Wing. The exit access corridor between Stair S5 and S4 is a 100 ' dead end corridor and does not comply with 19.2.5.9.

a. The corridor is directed towards a 2nd Floor ICU Suite that is vacant. Stair S4 is inside the suite.

b. The pair of 1 ½ hour fire doors at the east end of the corridor are locked with a magnetic locking device that prevents further travel to the east. This pair of door is identified as a horizontal exit. There is an exit sign above the doors. The doors do not comply with 7.2.6, 7.2.1.6.1 or 7.2.1.6.2. Access to Stair S4 is blocked by these locked doors.

4. There are two sets of cross corridor doors in the 1st Floor corridor near Room A103. The 2nd set of doors have magnetic locking devices but lacks the 15 second delay signage that is require by 7.2.1.6.1. Further, the surveyors find that these locks are located in an area that is not fully sprinklered and the locks are not permitted under 7.2.1.6.1.

5. 1st Floor OP Surgery (Dwing): The suite has a pair of auto-open 1 ½ hour doors that open to the exit passageway. The doors have magnetic locking devices but lack a sign complying with 7.2.1.6.1.


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B. Based on observation, the facility failed to keep all means of egress readily accessible at all times in accordance with 7.1.

Findings include

1. On 2/07/13 in the afternoon during fire alarm testing with the Construction Planning Mgr., the surveyor observed that the fire alarm did not release the cross corridor doors at the West end of the Labor/Delivery Unit outside patient room A103. More than 15 lbs. of force was required to open the Labor/Delivery Unit doors manually, therefore the surveyor finds that the doors do not meet 7.2.1.4.5 and/or 7.2.1.6.1.

2. On 2/07/13 in the afternoon during fire alarm testing with the Construction Planning Manager, the surveyor observed that since the area the cross corridor doors at the West end of the Labor/Delivery Unit outside patient room A103 of the building is not sprinklered or the two smoke compartments that are adjacent to this pair of doors do not have smoke detection throughout, the delayed egress locks are not permitted under 7.2.1.6.1.

3. On 2/07/13 in the afternoon during fire alarm testing with the Construction Planning Manager, the surveyor observed that there were two delayed egress locks on each leaf of the cross corridor doors at the West end of the Labor/Delivery Unit outside patient room A103. Twos locks are not permitted under 7.2.1.6.1.

A. Based on observations during the survey walk-through, the facility failed to provide and maintain properly rated fire-resistance horizontal exits, in accordance with NFPA 101, 18.2. Without the barriers being constructed and maintained, the buildings are not properly separated and a fire could spread from one building to the other.

Findings include:

On 2/5/13 at 11:35 AM, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that the 2-hour Fire Wall separating the East Tower from the 350 Building was deficient. Upon investigation it was determined that the designated 2-hour rated wall, per facility Life Safety drawings dated 10-9-09, was "not" sealed above the suspended ceiling at the cross-corridor doors. The cross corridor wall and corridor wall intersection (corners) was incomplete. The unsealed penetrations lack fire rated material in accordance with NFPA 101, 8.2.2.2.


B. Based on observations during the walk through the facility failed to provide fire doors in accordance with LSC Sections 8.2 and 18.1.2.3 and NFPA 80 Sections 1-11.4 and 2-3.1.7. Without doors and proper hardware, the fire could spread from one compartment to another.

Findings include:

On 2/5/13, 1st floor, 2 hour separation wall between OR and OB/LDR, by C-Section room. It was observed that the cross corridor doors are 90 minute rated doors. It could not be determined if the door hardware installed is listed for 90 minute fire doors. This condition was discussed with the Director of Engineering at the time of the finding. Listing documentation for the door hardware was not available.

A. Based on observation, the facility failed to provide normal and emergency lighting of the means of egress as required by 39.2.8 and 39.2.9, as well as 7.8 and 7.9.

1. On 2/07/2013, surveyors with Director of Engineering observed that there was no illumination of the exit discharge from the North exit passageway of the First Floor of the Radiology/Mammography Unit of the Pavilion.

2. On 2/07/2013, surveyors with the Director of Engineering observed that the facility did not provide two fixtures or a two bulb fixture as required by 7.8.1.4 so that the failure of a single bulb will not leave the exit discharge from the North exit passageway of the First Floor of the Radiology/Mammography Unit of the Pavilion in darkness.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed a vestibule corridor that is east of the 5th Floor ICU Suite. This vestibule has a pair of fire doors to the east that lack a sign that indicates "not an exit" on the west side of these doors, in accordance with 7.10.8. There is no exit path to the east beyond these doors.

B. Stair # S-2 is identified as a convenience stair by the provider. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed signs are not installed on the stair door that indicates "not an exit" on the corridor side of the stair door, in accordance with 7.10.8. This condition applies to Floors 1 through 5.

C. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that 3rd Floor Interconnect Wing lacks an illuminated exit sign to the east.

Based on document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During a review of the facility's fire protection plan documents, including Life Safety Plans dated 10/09/09, it was determined that the facility has not prepared and maintained comprehensive building information, which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Identification of construction types, as defined by NFPA 220, for each different part of the building. Separations between buildings are not clearly defined. There are a lot of two hour barriers that do not define building separations. In some cases, it is not clear which building an area is part of

2. Ventilation, duct, and pipe shafts and their fire resistance ratings.

3. Plans do not identify the Elevator Identification Numbers that are used for the building.

3. Fire barrier walls and/or horizontal exits.

4. Smoke barrier walls; The Life Safety Plans dated 10/09/09 that were furnished by the provider for the survey do not clearly identify the size of smoke compartments for each floor or zone. Further the plan key identifies smoke barriers and one, two and three hour smoke resistant walls. The smoke barriers and ratings are not clearly identified. The Plan Key does not clearly indicate that the smoke resistant walls are intended to identify smoke barriers.

5. Hazardous area enclosures and their fire resistance ratings.

6. Accurate and current information identifying the extent of sprinklered protection of the building.

7. Designated suites, suite boundaries

8. All exit access corridors.

10. Use of areas, occupancies in some areas along legible labeling of room uses and room numbers. The plans provided were too small to read.

11. An exit analysis is provided for the entire complex; however, it is not evaluated separately for each floor. Some floors do not have access to all exit stairs identified. Examples: Two exit stairs in the East Building are not available to all buildings at the 2nd, 4th and 5th Floor. Stair S10 is not currently available to all floors of the 350 Building.

Based on document review for the previous 12 months, the facility failed to perform fire drills at least once per quarter per shift.

1. On 2/05/13 at 4:00 PM with Director of Biomed and Safety, the surveyor observed that no drill was conducted during the third shift for the Second Quarter of 2012 as required by LSC Section 19.7.1.2.

Based on observation the facility failed to provide and maintain a fire alarm system with approved devices or equipment installed according to NFPA 101, 2000 Edition, Sections 18.3.4 and 9.6.2 NFPA 72, (1999) 8.2.2. This deficient practice could affect all building occupants if the fire alarm system failed to operate during a fire.


Findings include:

1. On 2/5/13 at 1:12 PM, 3rd floor, West Horizontal Exit, between ICU and Ortho, during the walk through of the facility with the Director of Engineering, the area lacks a manual fire alarm pull station within 5 feet of the cross corridor doors at the horizontal exit. The drawings provided to the surveyor, dated 10/9/9, indicate the horizontal exit on the North side of the cross corridor doors leading South into Ortho from ICU. Clarification is needed to determine if this is a horizontal exit in both directions and if manual fire pull stations are required on the North and South sides of the exit.

2. On 2/5/13 at 1:15 PM, 3rd floor, East Horizontal Exit, between ICU and Ortho, during the walk through of the facility with the Director of Engineering, the area lacks a manual fire alarm pull station within 5 feet of the cross corridor doors at the horizontal exit. The drawings provided to the surveyor, dated 10/9/9, indicate the horizontal exit on the North side of the cross corridor doors leading South into Ortho from ICU. Clarification is needed to determine if this is a horizontal exit in both directions and if manual fire pull stations are required on the North and South sides of the exit.

The facility failed to maintain the fire alarm system in accordance with NFPA 72, Section 7.1.1.2.

1. Based on document review, several items in the contractor's fire protection test report of 6/18/12 were noted as deficient. There was no evidence of correction.

Based on fire alarm record reviews and observations, the facility failed to properly install, test or maintain the fire alarm system in accordance with NFPA 101, 2000 Edition, Section 9.6 as well as NFPA 70 and NFPA 72.

Findings include:

On 2/7/13, 5th floor, center corridor the smoke detector was observed over four feet down from the highest point of the ceiling / roof area. The detectors in this area are not installed in accordance with NFPA 72, 2-3.4.1.

A. Based on document review and interview of the project architect of record, the surveyor finds that the East Tower is new health care occupancy and is required to be fully sprinklered in accordance with 18.3.5.1. The new building is fully sprinklered; however, it is not separated from the 350 Building by two hour fire rated construction and portions of the 350 Building are not sprinklered.

Findings include:

1. The 3rd Floor of the East Tower is separated from the 3rd Floor of the 350 Building by a one hour smoke barrier and not a two hour fire barrier. Based on the Life Safety Plans dated 10/09/09, portion of the 3rd Floor of the 350 Building are not sprinkled, therefor the East Tower does not comply with 18.3.5.1.

2. The 1st Floor of the East Tower is separated from the unsprinklered portions of the 1st
Floor of the 350 Building by a one hour smoke barrier and not a two hour fire barrier. Based on the Life Safety Plans dated 10/09/09 and based on direct observation with the Director of Safety present, the surveyor finds that portion of the 1st Floor of the 350 Building are not sprinkled, therefor the East Tower does not comply with 18.3.5.1.

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A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyor finds that the sprinkler system is not installed and maintained in accordance with NFPA 13 and NFPA 25:

Findings include:

1. 1st Floor Imaging Department - the MRI Equipment Room has voids in the ceiling and/or missing ceiling tiles that compromises both fire suppression and detection in this space.

Based on observation it was determined that the facility failed to properly inspect and document the maintenance of all portable fire extinguishers in accordance with NFPA 101, 2000 Edition 18.3.5.6, 9.7.4.1 and NFPA 10. All fire extinguishers must be mounted or secured in a safe attachment that would be accessible to staff in an emergency.

Findings include:

On 2/5/13 at 12:00 PM, during the walk through of the facility with the Director of Engineering, it was observed on the 3rd - 4th floor interstitial space, entering from Stair S16. As you enter the room on the right hand side is a sign identifying the location of a " fire extinguisher " ; however the extinguisher was not installed below the sign.

A. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed the HVAC installations are not installed and maintained in accordance with NFPA 90A.

Findings include:

1. 4th Floor Interconnect Wing: The Dialysis Locker Room has a new washer and dryer installed in this space. The provider had no information or knowledge as to how the dryer exhaust was directed to the outside.

A. Based on document review for Kitchen Hood Suppression systems, for semi-annual inspection, testing and maintenance for the past 12 months, the surveyor finds that the documentation for both kitchen hoods (Main Kitchen and Servery) does not comply with NFPA 17A and NFPA 96.

Findings include:

1. The semi annual inspections failed to find and identify the lack of separation between the fryers and open flames in the adjacent equipment in the Main Kitchen.

2. The documentation for the Main Kitchen and Servery is combined on one form for each semi-annual inspection. The documentation does not identify specifically the appliances protected under each hood and the documentation does not identify the number or type of links that were replaced for each system.

3. Based on observation with the Director of Safety and the Director of Corporate Facilities on 10/07/09, the surveyor finds that the kitchen hood suppression system for the 1st Floor Servery has an ANSUL pull station that is not in the path of egress from the protected system and further the path is obstructed and does not comply with NFPA 17A. This also does not show up on semi-annual inspection reports.


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B. The surveyor finds on the morning of 2/6/13 while in the company of the Director of Plant Operation & Maintenance at the First Floor Kitchen (South Building), protection of cooking surfaces are not provided either by separation or barrier at the deep fat fryer to the adjacent open flame range in noncompliance with NFPA 96, 1998, 9-1.2.3.

A. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that Office B307 has a portable electric heater that does not comply with 19.7.8.

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyor finds that exit access corridor are obstructed and not maintained in accordance with 7.1.10.

Findings include:

1. The 5th Floor exit access corridor north of the Rehab Suite to Stair S11 is partially obstructed by chairs and a fish tank.

2. The required 5th Floor exit access corridor from the Rehab Suite extending west to Stair S10 is partially obstructed by chairs and benches in the corridor. See also K038.

3. The 2nd Floor of the 400 Building is an inpatient psychiatric unit. There is a vestibule at the south end of the exit access corridor that provides access to Stair S5 and to an adjacent horizontal exit. This vestibule was obstructed to less than 8 ' -0 " in width by two benches and an unattended housekeeping cart.

Based on observation with the Director of Safety and the Director of Corporate Facilities the surveyor finds medical gas tanks are not stored in accordance with NFPA 99 - 1999.

Findings include:

1. Basement Level of the 400 Building. Respiratory has oxygen tanks that are stored closer than 5'-0" to combustibles.

The surveyor find on the afternoon of 2/5/13 while in the company of the Director of Plant Operation & Maintenance at the Basement Level (East Building), unrelated electrical equipment (maintenance shop air compressor & public address system amplifier) installed within the medical gas manifold room (304) as prohibited by NFPA 99, 1999, 4-3.1.1.2, (a) 10.

Based on random observation during the survey walk-through while accompanied by the lead engineer and the building operations manager , the surveyor found that the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.

Findings include:

1. The pavilion emergency generator did not have a remote shut down switch to comply with NFPA-110, Section 3-5.5.6.

2. The pavilion generator did not have a remote annunciator or a derangement signal at a 24 hour staffed location to meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

A. 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.

1) The provider failed to implement and document adequate interim life safety measures for the conditions cited.

Based on random observation during the survey walk-through while accompanied by the lead engineer and the building operations manager, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 99 (1999).

Findings include:

All medical gas system alarm points are not monitored at the master alarm panel at a continuously attended location in accordance with NFPA-99, Section 4-3.1.2.2(b)2 and (b)3.

Based on random observation during the survey walk-through while accompanied by the lead engineer and the manager of building operations, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include but are not necessarily limited to:

1. Critical panel C3B was serving the medical gas alarm panel. This does not meet the requirements of NFPA-70, Section 517-32 and 33. Medical gas alarm panels are one of the items listed in NFPA-70, Section 517-32 that shall only be served from the life safety branch of the emergency system.

2. Life Safety panels E63 and E66: The nurse call equipment is connected to the Life Safety Branch of emergency power instead of the Critical Branch, in accordance with NFPA-70, Section 517-32.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed that electrical installations and materials do not comply with NFPA 70 - 1999. Findings include

1. Electrical extension cords are used for permanent electrical service and do not comply with NFPA 70: Valentine Day string of lights at the 5th Floor ICU Nurse's Station

Based on random observation during the survey walk-through while accompanied by the lead engineer and the manager of building operations, portions of the elevator control system are not installed in accordance with ASME A17.3. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1. Elevator 6 and 7 (surgical elevators): The machine room (hydraulic) in the Lower Level was not equipped with a smoke detector for elevator recall as required by ASME A17.3-211.3.

2. The surveyors observed that the surgical elevator machine room had a louvered doors. The machine room is a hazardous area and the louver does not comply with 7.2.1.8 of NFPA 101. and/or ASME A17.3.

3. The surveyor observed that the elevator machine room for elevator 6 and 7 was not equipped with a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.3-102.2.c.3.

4. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects for elevators 1, 2, 3, 4, 5, 6, and 7 as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.