BHC Streamwood Hospital in Streamwood, IL was cited by the Centers for Medicare and Medicaid Services (CMS) during a Medicare Sample Validation Survey, for deficiencies related to life safety code standards.
CMS found that four of four floors in the building had a plenum return air system that did not comply with life safety codes. CMS found:
“In most portions of each floor every room communicates above the ceiling to every other room with a plenum return air system. The plenum return air system communicates to the nurse’s station and rooms around the nurse’s station on each floor. None of the rooms on each floor communicate directly to the exit access corridors, except at the nurse’s station.”
CMS noted that “[t]he lack of fire and smoke dampers for these shaft enclosures will allow smoke to pass from floor to floor to floor and will readily compromise all corridors and all rooms during a fire emergency.”
CMS also found a “mechanical mezzanine above the 1st floor maintenance space between the gym and the kitchen that did not meet the requirements of a mezzanine because it has a 3’ by 8’ floor opening with a ships ladder and is open to the 1st floor hazardous area.”
Additional life safety violations included doors that did not latch, improper installation and maintenance of the sprinkler system and electrical wiring that did not meet code.
As a result, CMS imposed Interim Life Safety measures, which included notification of the Fire Department, daily monitoring of affected areas, Fire Watch protocols and an increase in the number of fire drills at the facility.
On September 9, 2012, CMS returned for a Federal Monitoring Survey. CMS found that the facility had repaired some of the deficiencies found in the April survey, but still had the plenum return air system in place and the first floor mezzanine still did not meet applicable fire codes.
CMS returned again on June 26, 2013, more than a year after the initial survey. In its third inspection, CMS found that the facility still had the plenum return air system and the first floor mezzanine still did not meet fire safety codes. The facility once again submitted a plan of correction to address these deficiencies, and CMS noted that the plans were completed on December 30, 2013.