There are  42 surveys for this facility. Please select a date to view the survey results.

Finding 1) The penetration in the fire wall across from data closet with door M2-38b was repaired with appropriate firestopping material with matched UL Rating. This was verified by the Director of Facilities.
Finding 2) Fire Wall with exposed studs was repaired with fire-rated drywall and taping to meet wall listed rating.
The Director of Facilities will contract or perform a complete above-ceiling fire-barrier inspection annually to ensure sustained compliance. The results of the first inspection will be provided to the Environment of Care Committee 12 months from implementation along with any needed corrective actions. Inspections will continue annually thereafter.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. All actions will be completed by 8/31/2023.

Finding 1) Light in stairwell next to room 499 on the 4th floor has been replaced and is operational. This was verified by the Director of Facilities.
The Director of Facilities has created a monthly preventative-maintenance work order to verify proper illumination of all stairwell lighting in the component. The Environment of Care Committee, on rounding, will add verification of stairwell lighting in the surveyed areas to the rounding documentation reports.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. All actions will be completed by 8/31/2023.

Finding 1) In fist floor stair # 6, rated access doors have had proper closure hardware installed and positive latching verified. This was verified by the Director of Facilities.
The Director of Facilities has created an annual preventative-maintenance work order to verify proper operation of all stairwell doors and rated access panels. The EOC committee, on rounding, will add verification of stairwell doors and access panels in the surveyed areas to the rounding documentation reports.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. All actions are complete.

Finding 1) In first floor ED zone 1 soiled room, unsealed penetration above the suspended ceiling on the outside wall has been sealed to a smoke-tight condition. This was verified by the Director of Facilities.
The Director of Facilities has contracted an outside vendor to perform a complete above-ceiling fire-barrier inspection annually to ensure sustained compliance. The results of the first inspection will be provided to the Environment of Care committee 12 months from implementation along with any needed corrective actions. Inspections will continue annually thereafter.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. All actions are complete.

Finding 1) The cart blocking the pull station on the 5th floor next to resident room 528. This was verified by the Director of Facilities.
The Director of Facilities will provide training to department heads to train hospital staff on the clearances for pull stations. Environment of Care rounding documentation will be modified to ensure continued compliance verifying that clearances for pull station and initiations are maintained. Resulting data will be presented monthly for three months of continuous compliance and departments not meeting the requirement will receive additional training.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding will be complete by 8/31/2023.

Finding a) Open penetration 3rd floor, stair exit B, above door A-302
Finding b) Open penetration near West doors
Finding c) Open penetration, 2nd floor, side entrance to IS Department, by data wires and a sprinkler pipe
Finding d) Open penetration, 2nd floor, above M2-803B, large penetration
Finding e) Open penetration, 2nd floor, Locker Room (door M2-68a), by data room
Finding f) Open penetration, above door M2-69
The open penetrations have been repaired with appropriate firestopping material with matched UL Rating. This was verified by the Director of Facilities.
The Director of Facilities will contract or perform a complete above-ceiling fire-barrier inspection annually to ensure sustained compliance. The results of the first inspection will be provided to the Environment of Care Committee 12 months from implementation along with any needed corrective actions. Inspections will continue annually thereafter.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding will be complete by 8/31/2023.

Finding 1) The portable AC unit being used in the space was removed from service during the tour and will not be reinstalled.
The space has received a new air handler and portable units are no longer necessary.
The Director of Facilities will ensure in future situations where a temporary portable air-conditioner is necessary that it does not utilize an open ceiling cavity for any purpose. If temporary cooling is needed it will be vented appropriately to a piped exhaust plenum or direct building exhaust. A hospital policy will be developed to address this specific issue.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding will be complete by 8/31/2023.

Finding a) 2nd floor, Electrical closet across from the pantry, blocked by ladders
Finding b) 2nd floor, Electrical closet (door M2-48d), blocked by ladders
Finding c) 2nd floor, Electrical closet (door M2-07), blocked by ladders
Ladders have been removed from all electrical closets, including electrical closet across form pantry, electrical closet M2-48d, and electrical closet M2-07, and signage installed noting that no ladders or other items are to be stored in electrical closets.
The Environment of Care (EOC) Committee will add checking electrical closets for storage during rounding. This has been added to the EOC rounding form template. Elimination of electric closet storage compliance from EOC rounding will be reported to the EOC Committee for three consecutive months of 100% compliance.

Facilities Director is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.

Finding 1) Electrical receptacles at resident bed locations, and in locations where deep sedation of general anesthesia is administered, were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, nor were hospital grade receptacles tested based on documented performance data, minimally not exceeding 12 months.
All patient care area receptacles have been tested and documented including any corrective actions.
The Environment of Care Committee will review the annual electrical receptacle testing documentation and verify completion for 2 cycles beginning in July 2024.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.

Finding 1) Inside Electric Room A3-14, there was a section of missing spray fireproofing on a structural beam.
The missing fireproofing has been replaced.
The Director of Facilities will contract or perform a complete above-ceiling fire-barrier inspection annually to ensure sustained compliance that will include fireproofing in mechanical and electrical rooms with and without a suspended ceiling. The results of the first inspection will be provided to the Environment of Care Committee 12 months from implementation along with any needed corrective actions. Inspections will continue annually thereafter.

The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.

Finding 1) First Floor Auditorium Stage Room unsealed penetration around a copper pipe.
The missing firestopping has been replaced.
Environment of Care rounding documentation has been modified to ensure continued compliance verifying that clearances for pull station and initiations are maintained. Resulting data will be presented monthly for six months of continuous compliance.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.

Finding 1) First Floor Auditorium both sides exit stair, battery back-up lighting, failed to illuminate when tested.
The defective lighting units have been replaced.
Environment of Care rounding documentation has been modified to ensure continued compliance verifying that battery backup lighting units are tested during rounding. Resulting data will be presented monthly for six months of continuous compliance.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.

Finding 1) Ground floor AG04 Storage closet, items were stored within 18 inches of the sprinkler.
The storage within the 18" barrier has removed.
A line denoting the 18" clearance line for the sprinkler (below the ceiling line) has been painted on the walls and staff notified to maintain clearance. Environment of Care (EOC) rounding documentation will be modified to ensure continued during rounding compliance verifying that no items are stored within 18" of the ceiling and sprinkler head. Resulting data will be presented monthly to the EOC Committee for six months of continuous compliance.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.

Finding a) Fire extinguisher not properly mounted or obstructed at Virology Room near entry door.
Finding b) Fire extinguisher not properly mounted or obstructed at Virology Room
Finding c) Fire extinguisher not properly mounted or obstructed by entry door to power plant control room
The fire extinguishers listed above have been properly wall mounted.
A pass/fail line item for monthly fire extinguisher inspections has been added to the compliance documentation form maintained for said inspections and will ensure monthly verification of proper mounting. Environment of Care rounding documentation will be modified to ensure continued during rounding compliance verifying that fire extinguishers in the surveyed areas are properly mounted. Resulting data will be presented monthly to the EOC Committee for six months of continuous compliance.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.

Finding 1) In mechanical room by Clinical Molecular Cytogenics, an extension cord was plugged into a fan.
Finding 2) On the loading dock outside the doors to the receiving room a junction box was missing a protective cover.
Finding 3) On the first floor in the Auditorium stage room the electrical panel was missing a circuit breaker protective blank.
The extension cord in Clinical Molecular Cytogenics has been removed. A cover has been installed on the junction box on the dock outside the receiving room. A protective blank has been installed where there was a missing circuit breaker in the panel in the Auditorium Stage Room.
Environment of Care rounding documentation has been created to ensure continued compliance by verifying no extension cords are present in the surveyed departments, that all junction boxes have appropriate covers, and that no open spaces (missing breaker) spots exist in electrical panels that do not have a protective cover. Resulting data will be presented monthly for six months of continuous compliance.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.

Finding 1) In the loading dock Receiver's Office a refrigerator was plugged into a surge protector.
The surge protector connected to the refrigerator in the dock Receiver's office has been removed. A wall receptacle meeting NFPA 70 will be installed to relieve the need for a surge protector.
The Facility Director will ensure that all new appliance installations are done with sufficient electrical receptacle capacity serving the device. Environment of Care rounding documentation will be modified to ensure continued compliance by verifying no appliances are plugged into surge protectors. Resulting data will be presented to the EOC Committee monthly for six months of continuous compliance.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.

Finding 1) There was an oxygen storage tank cart located inside the engineering department. The room lacked "CAUTION: OXYDIZING GAS(ES) STORED WITHIN NO SMOKING" signage.
Finding 2) Two freestanding oxygen cylinders were found inside the oxygen room at the ground floor loading dock.
The resolution to the first finding is the storage area in the maintenance department has had proper oxygen signage added. For the second finding, the oxygen tanks were secured onsite at the time of survey.
Environment of Care rounding documentation has been modified to ensure continued compliance by verifying O2 signage is present in any areas where oxygen is stored in bottles and that any and all oxygen bottles are safely secured. Resulting data will be presented to the EOC Committee monthly for six months of continuous compliance.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.

Finding 1) Inside Electric Room A3-14, there was a section of missing spray fireproofing on a structural beam.
The missing fireproofing has been replaced.
The Director of Facilities will contract or perform a complete above-ceiling fire-barrier inspection annually to ensure sustained compliance that will include fireproofing in mechanical and electrical rooms with and without a suspended ceiling. The results of the first inspection will be provided to the Environment of Care Committee 12 months from implementation along with any needed corrective actions. Inspections will continue annually thereafter.

The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.

Finding 1) Chairs and cones were stored under the landing in 1st floor stair tower C.
The chairs and cones stored under the landing in 1st floor stair tower C have been removed. A new proper storage location has been designated for these items.

Environment of Care rounding documentation has been modified to ensure continued compliance verifying that stair towers remain clear. Resulting data will be presented monthly to the EOC Committee for six months of continuous compliance.
The Director of Facilities is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.

Finding 1) The tower fire pump room, 2 sprinkler gauges were dated 2015, exceeding the 5-year service interval. Evidence of calibration was not available at time of survey.

The pressure gauges in the Tower fire pump room have been replaced with new.

An annual work order has been created for the Facilities Department to verify the ages of all sprinkler gauges to assure replacement. 1st year results will be presented to the Environment of Care (EOC) Committee. In addition, age-of gauge confirmation of sprinkler system gauges has been added to Environment of Care rounding documentation for verification. This will be presented monthly by the EOC Committee for six months of continuous compliance.

Finding a) 3rd floor electrical transformer room A2332, had an unsealed penetration on the wall around conduit

Finding b) 3rd floor electrical transformer room A2332, had expanding foam around a conduit

In the 3rd Floor electrical transformer room (A2332) the unsealed penetration on the wall around the conduit has been properly sealed.

In the 3rd Floor electrical transformer room (A2332) the expanding foam around the conduit has been fully removed.

Moving forward St. Christopher's will utilize approved through penetration fire-stop systems to seal penetrations through rated partitions.

The Environment of Care Committee will add checking electrical and mechanical closets/rooms for unsealed penetrations and prohibited expanding foam to the documentation rounding template. This will be utilized on all Environment of Care rounds. Environment of Care (EOC)rounding team members will be educated by the Director of Facilities on the appearance of expanding foam and missing firestop/sealant to better identify any deficiencies. Results of EOC findings on these items will be presented monthly at the EOC Committee meeting for six months of consecutive compliance.

The Facilities Director is ultimately accountable for the corrective actions and ongoing compliance with this standard. Immediate compliance actions for this finding are complete.