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Based on observations and confirmed by staff, the facility failed to ensure that corridor doors are maintained as required.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/24/14 through 2/3/14 revealed that the corridor door's latch mechanism to room #202 on the Pratt/Farnsworth second floor unit does not close and latch in it's frame. The door hinge has pulled from the door frame causing the door to hit the door frame when attempting to close.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that corridor doors are maintained as required.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/24/14 through 2/3/14 revealed that the corridor door's latch mechanism to room #202 on the Pratt/Farnsworth second floor unit does not close and latch in it's frame. The door hinge has pulled from the door frame causing the door to hit the door frame when attempting to close.


This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that corridor doors are maintained as required.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/27/14 through 2/3/14 revealed that:

1. The corridor doors identified as F6.11 & F6.19 in the Floating Building's sixth floor level PICU Suite have a space between the door leaf(s) greater than 1/4 "at the door's meeting edges. This is greater than the allowable 1/8".

2. The corridor door identified as F4.10, in the Floating Building's fourth floor level, has a broken door coordinator impeding the door from closing properly when released from the open position.

3. The seventh floor level corridor door, identified as F-7.9 , have ½ " diameter holes through the door slab where magnetic locking plates were removed. It also has a ¼ " gap at the doors meeting edges.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

A. Based on observations the facility failed to ensure that corridor doors protecting openings in corridor walls are constructed as required. NFPA 101 Life Safety Code 2000 Edition Chapter 19.3.6.4 prohibits transfer grilles, regardless of whether they are protected by fusible link operated dampers, to be used in corridor walls and doors. Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets and similar auxiliary spaces that do not contain flammable or combustible materials shall be permitted to have ventilating louvers or to be undercut.

THE FINDINGS INCLUDE:

1. Observations while touring the facility on the morning of 1/27/13, at approximately 11:30 am, revealed the existence of a 2' x 2' transfer grille in the door of Room 249A. Room 249A is located off an exit corridor on the second floor of the Proger building and is used for the storage of non flammable, non oxidizing inert medical gases (carbon dioxide and liquid nitrogen).

Note: The room is of the proper fire resistive rating for the storage of the above-mentioned medical gases.


B. Doors leading to suites of room must comply with Chapter 19, Section 19.3.6.3.2 of the 2000 Edition of NFPA 101 Life Safety Code. Section 19.3.6.3.2 states corridor doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

THE FINDINGS INCLUDE:

1. Observations while touring the facility during the afternoon of 1/30/14, at approximately 2:15 pm, revealed that the inactive leaf of the entrance doors to the Nuclear Imaging Suite is equipped with manual latching flush bolts. In order for the active leaf to positively latch on a consistent basis the inactive leaf must be equipped with an automatic latching flush bolt.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observations, the facility failed to assure that vertical shafts are enclosed as required.

THE FINDINGS INCLUDE:

Observations while touring the Floating Building's eighth floor level on 1/28/14 revealed that the walls enclosing the vertical H.V.A.C. shaft are open to the adjacent mechanical space. This H.V.A.C. shaft, which was identified as having a 2 hour rating on plans dated 12/13/13, is open due to unsealed gypsum wallboard (GWB) penetrations around the approximate 16" diameter duct behind the service elevator, E003.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations the facility failed to ensure that stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with NFPA 101 Life Safety Code 2000 Edition, Chapter 8, Section 8.2.5.6.

Section 8.2.5.6. states unless prohibited by Chapters 12 through 42, an atrium shall be permitted, provided that the following conditions are met:
(1) In other than existing, previously approved atria, atriums are separated from the adjacent spaces by fire barriers with not less than a 1-hour fire resistance rating with opening protectives for corridor walls. (See 8.2.3.2.3.1(2), Exception No. 1.)
Exception No. 1: Any number of levels of the building shall be permitted to open directly to the atrium without enclosure based on the results of the engineering analysis required in 8.2.5.6(5).
Exception No. 2*: Glass walls and inoperable windows shall be permitted in lieu of the fire barriers where automatic sprinklers are spaced along both sides of the glass wall and the inoperable window at intervals not to exceed 6 ft (1.8 m). The automatic sprinklers shall be located at a distance from the glass not to exceed 1 ft (0.3 m) and shall be arranged so that the entire surface of the glass is wet upon operation of the sprinklers. The glass shall be tempered, wired, or laminated glass held in place by a gasket system that allows the glass framing system to deflect without breaking (loading) the glass before the sprinklers operate. Automatic sprinklers shall not be required on the atrium side of the glass wall and the inoperable windows where there is no walkway or other floor area on the atrium side above the main floor level. Doors in such walls shall be glass or other material that resists the passage of smoke. Doors shall be self-closing or automatic-closing upon detection of smoke.

THE FINDING INCLUDES:

Observations while conducting the facility tour on the afternoon of 1/27/14, at approximately 1:15 pm, revealed the set of glass doors to the entrance of the pharmacy, located on the third floor of the Proger building, are lacking self-closing devices and were being held open with magnetic devices which are not tied into the smoke detection system. (The glass doors are part of a tempered glass partition wall with automatic sprinklers positioned on both sides of the wall at spaced intervals in accordance with regulations. )

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observations, the facility failed to assure that smoke detectors for door release are installed in accordance with NFPA #72. Where the depth of the wall section above the door is less than 24 inches Section 2.10.6.2.5.1.1 and Figure 2.10.6.2.5.1.1 require one smoke detector to be placed within 5 feet of the door and not less than 12 inches from the door. NOTE: If the depth of the wall section above the door is more than 24 inches an additional smoke detector may be required.

THE FINDINGS INCLUDE:

Observations while touring the Floating Building's seventh floor level on 1/27/14 and 1/28/14 revealed that there are no smoke detectors installed on or near the doors separating the Floating Building and the Prodger Building. There is approximately 11 feet of wall above each side of the door.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations, the facility failed to assure that smoke detectors for door release are installed in accordance with NFPA #72. Where the depth of the wall section above the door is less than 24 inches Section 2.10.6.2.5.1.1 requires one smoke detector to be placed within 5 feet of the door and not less than 12 inches from the door.
Section 2-10.6.5.1.2* states the following:
If the depth of wall section above the door is greater than 24 in. (610 mm), two ceiling-mounted detectors shall be required, one on each side of the doorway.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 1/29/14, at approximately 2:30 pm, revealed that the set of doors which are incorporated into the rated barrier separating the Atrium from the eighth floor of the Proger building are deficient. On the Atrium side, the wall section above the doors is approximately forty-eight inches in depth and is without a smoke detection device as required for door release.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

While performing the tour of the Pratt Building seventh floor level on 1/29/14, it was observed that the corridor door to the Soiled Utility Room, labeled #726, is not equipped with a closing mechanism. When released from the open position, the door would not automatically close and latch into the door frame as required.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

While performing the tour of the Floating Building operating rooms on 1/29/14 at approximately 6:45 A.M., it was observed that the door to the dirty holding room (#529) is not equipped with a latching mechanism. When the door was tested for proper operation, the door would not close & latch into the door frame as required.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

B. Based on observations, the facility failed to assure that hazardous areas are enclosed as required. Section 19.3.2.1 requires the doors to rooms or spaces larger than 50 sq. ft. including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction, to be self-closing.

THE FINDINGS INCLUDE:

1. Observations while touring the facility on the morning of 1/28/14, at approximately 10:25 A.M., revealed that the door to Room 403, located on the fourth floor of the Proger building, is not self-closing. Room 403 is greater than fifty square feet in size and is used for the storage of large quantities of combustible supplies. Such conditions require the door to be self-closing.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observations, the facility failed to ensure that exit stairways are enclosed as required.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/27/14 through 2/3/14 revealed that:

1. Stair #2, located on the Floating Building's eighth floor level, is not constructed as required. A 1/4" space along the stair's meeting edge at the ceiling, adjacent to the 4 " x 8 " I-beam, leaves the stair open to the adjoining mechanical space.

2. The Floating Building's eighth floor level stair door from the playroom, connecting the playroom to the seventh floor level medical unit, is not equipped with a door rating label. Therefore, the separation between the eighth and seventh floor level is less than required.

3. The Floating Building's fourth floor level stair #3 (S003) enclosure has an unsealed space around the sprinkler pipe penetration which leads into the storage room (408S).

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations, the facility fail to maintain the requires means of egress. NFPA 101, Section 7-1.10.1 requires means of egress to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.2.1.6.1 states approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42. Section 7.2.1.6.1 (c)states an irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door.

THE FINDINGS INCLUDE:


While performing a building tour of the third floor of the North Building on 1/28/14 at approximately 3:00 P.M., it was revealed that the door to the stairwell has a delayed egress type look that must release 15 seconds after a force is applied on the door's panic bar releasing device. A test was performed by the surveyor by putting a force on the door's panic bar releasing device. The door lock did not release after the 15 second time period allowed by the code.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observation, the facility was not in compliance with Section 19.2.5. Section 19.2.5.7 allows suites of rooms, other than patient sleeping rooms, to be allowed if the suite does not exceed 10,000 ft2 (930 m2). If the treatment suite were to exceed 10,000 sq. ft. in area, it would cease to qualify for the suite provisions of 18/19.2.5. As such, this group of rooms and aisles would be required to comply with 18/19.2.3.3 relative to exit access minimum width and 18/19.3.6 relative to corridor walls and doors.

THE FINDINGS INCLUDE:

Based on observations and Life Safety Drawings dated 12/13/2013, the Neonatal Intensive Care Unit (NICU) Suite D2-B, located on the 2nd floor of North, is 14,366 ft2 which is not in compliance with Section 19-2.5.7.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observation, the facility was not in compliance with Section 19.2.5. Section 19.2.5.7 allows suites of rooms, other than patient sleeping rooms, to be allowed if the suite does not exceed 10,000 ft2 (930 m2). If the treatment suite were to exceed 10,000 sq. ft. in area, it would cease to qualify for the suite provisions of 18/19.2.5. As such, this group of rooms and aisles would be required to comply with 18/19.2.3.3 relative to exit access minimum width and 18/19.3.6 relative to corridor walls and doors.

THE FINDINGS INCLUDE:

Based on observations and Life Safety Drawings dated 12/13/2013, the Operating Room Suite F5-A, located on the 5th floor of Floating, is 22,449 ft2 which is not in compliance with Section 19-2.5.7.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

The facility was not in compliance with Section 19.2.5.6 which states suites of sleeping rooms shall not exceed 5,000 ft2.

THE FINDINGS INCLUDE:

Based on observations and Life Safety Drawings dated 12/16/2013, the Surgical Intensive Care Unit located on the fifth floor of the Proger building contains 5,623 ft2. The unit is 623 ft2 in excess of the maximum allowable size.

The finding was confirmed by the Director of Facilities Management during the exit conference.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground.

THE FINDINGS INCLUDE:

1. While performing a building tour of the seventh floor of the North Building on 1/27/14 at approximately 3:00 P.M., it was revealed that the set of ninety minute fire rated doors D7.8, accessing the horizontal exit separating the seventh floor from the Atrium stairway, are rubbing against the frame prohibiting the doors from latching properly.

2. While performing a building tour of the sixth floor of the North Building on 1/27/14 at approximately 4:00 P.M., it was revealed that the set of ninety minute fire rated doors D6.7, accessing the horizontal exit separating the seventh floor from the Atrium stairway, has an air balancing issue between the North and Atrium buildings that will not allow the doors to latch.

3. While performing a building tour of the fifth floor of the North Building on 1/28/14 at approximately 11:00 A.M., it was revealed that the set of rated doors D5.6, accessing the horizontal exit separating the seventh floor from the Floating building stairway, are labeled as forty five minute fire doors and not the required ninety minutes.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/27/14 through 2/3/14 revealed that the Floating Building's third floor level corridors C309 and C330, which lead to the Biewend Building and the garage, are equipped with light switches accessible to staff, patients and visitors. When these switches were tested for operation, entire corridors were put into complete darkness.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/29/14 that the Pratt Building's eighth floor level corridor to stair #2 is equipped with light switches accessible to staff, patients and visitors. When these switches were tested for operation, the entire corridors were put into complete darkness.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on staff interview, the facility failed to ensure compliance with section 7.9.2.3 which refers to NFPA 110 (Standards for Emergency Power Systems). NFPA 110, Section 6-4.2 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations. Section 6-4.3 requires load tests of generator sets to include a complete cold start.

THE FINDINGS INCLUDE:

Based on staff interview, 30 minute generator load tests are being conducted for the Courtyard emergency generator; however, these tests are not conducted from a cold start as required by NFPA 110, Section 6-4.3.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

A review of fire drill reports conducted on the afternoon of 1/29/14, at approximately 2:45 pm, revealed fire drills are not conducted as required. NFPA 101 Life Safety Code 2000 Edition Section 19.7.1.2 states fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

THE FINDINGS INCLUDE:

According to the fire drill documentation provided by the facility's Emergency Management Officer on the afternoon of 1/29/14, the following deficiencies were noted:

1. There is no record of a second shift ( 3 pm-11 pm ) fire drill being conducted for the fourth quarter of 2013.

2. There is no record of a third shift (11 pm-7 am ) fire drill being conducted for the second quarter of 2013.

3. Fire drills between the hours of 6:00 am and 9:00 pm are being conducted without the transmission of a fire alarm signal.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.


31165

A review of fire drill reports conducted on the afternoon of 1/29/14, at approximately 2:45 pm, revealed fire drills are not conducted as required. NFPA 101 Life Safety Code 2000 Edition Section 19.7.1.2 states fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

THE FINDINGS INCLUDE:

According to the fire drill documentation provided by the facility's Emergency Management Officer on the afternoon of 1/29/14, the following deficiencies were noted:

1. There is no record of a second shift ( 3 pm-11 pm ) fire drill being conducted for the fourth quarter of 2013.

2. There is no record of a third shift (11 pm-7 am ) fire drill being conducted for the second quarter of 2013.

3. Fire drills between the hours of 6:00 am and 9:00 pm are being conducted without the transmission of a fire alarm signal.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.
NFPA 92B section 5.4.1 states that during the life of the building, maintenance is essential to ensure that the smoke management system will perform its intended function under fire conditions. Proper maintenance of the system should, as a minimum, include the periodic testing of all equipment, such as initiating devices, fans, dampers, controls, doors, and windows. The equipment should be maintained in accordance with the manufacturer ' s recommendations. (See NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, for suggested maintenance practices.)
Section 5.4.2 states the periodic tests should determine that the installed systems will continue to operate in accordance with the approved design. It is preferable to include in the tests both the measurements of airflow quantities and the pressure differentials at the following locations:
(1) Across smoke barrier openings
(2) At the air makeup supplies
(3) At smoke exhaust equipment
All data points should coincide with the acceptance test location to facilitate comparison measurements.

Section 5.4.3 states the system should be tested at least semiannually by persons who are thoroughly knowledgeable in the operation, testing, and maintenance of the systems. The results of the tests should be documented in the operations and maintenance log and made available for inspection. The smoke management system should be operated for each sequence in the current design criteria. The operation of the correct outputs for each given input should be observed. Tests, if applicable, should also be conducted under standby power.

THE FINDINGS INCLUDE:

While performing the record review of the fire alarm system on 1/29/14 at approximately 9:00 A.M., it was observed that the facility has no records documenting testing of the smoke evacuation system. The facility contacted the fire alarm vendor at this time to secure any records for testing of this system. During the morning of 2/3/14 at approximately 8:00 A.M., it was revealed that no testing/inspections of the smoke evacuation system has been conducted in recent years. The facility in conjunction with the fire alarm vendor have no records of any testing of this system.

This was acknowledged by the Director of Engineering during the exit interview.

Based on record review and confirmed by staff, the facility failed to ensure compliance with NFPA #72. Section 7-3.2.1 states smoke detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

THE FINDING INCLUDE:

While performing the record review of the fire alarm system on 1/29/14 at approximately 9:00 A.M., it was observed that the sensitivity inspection/testing forms dated November 2013 indicate that approximately 75% of the smoke detectors located in the Floating Building failed the sensitivity test.

Note: It was stated by staff that the facility is implementing a plan for replacing all of the smoke detectors within the building.

This was acknowledged by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are properly supervised. Section 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

THE FINDINGS INCLUDE:

While viewing the sprinkler control valves on 1/30/14 at 10:00 A.M. it was observed that not all sprinkler valves are electronically supervised as required. The dry system OS&Y valve located on the street level of the Floating Building is not equipped with a supervisory device. It was observed that a new butterfly valve was installed above the existing OS&Y valve. Upon closer examination, it was observed that the supervisory switch was moved from the existing OS&Y valve to the new valve. However, the existing valve is still functional and has the capability of shutting the water supply off to the sprinkler system, therefore requiring supervision.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Section 5-3.2.1 states a weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.

Section 5-3.2.4 states the pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running.

Section 5-3.2.4.1 outlines the Pump System Procedure and what must be documented.
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.

Section 5-3.2.4.2 outlines the Electrical System Procedure and what must be documented.
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic stop controllers).

Section 3-3.1.1 states a flow test shall be conducted at the hydraulically most remote hose connection of each zone of a standpipe system to verify the water supply still adequately provides the design pressure at the required flow. Where a flow test of the hydraulically most remote outlet(s) is not practical, the authority having jurisdiction shall be consulted for the appropriate location for the test. A flow test shall be conducted every 5 years.

Section 9-4.4.2.2.1 states every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service. During those years when full flow testing in accordance with 9-4.4.2.2.1 is not required, each dry pipe valve shall be trip tested with the control valve partially open. Section 9-4.4.2.5 states a tag or card showing the date on which the dry pipe valve was last tripped and showing the name of the person and organization conducting the test shall be attached to the valve. Separate records of initial air and water pressure, tripping air pressure, and dry pipe valve operating condition shall be maintained on the premises for comparison with previous test results. Records of tripping time also shall be maintained for full flow trip tests.

THE FINDINGS INCLUDE:

While performing the record review of the sprinkler system on 1/29/14 at approximately 11:00 A.M., the following items were observed regarding the sprinkler systems:

1. The weekly fire pump test/inspection forms provided by the facility state the fire pumps are run for 10-minutes weekly while only documenting the suction & discharge pressures. There is no other information provided regarding the other testing criteria as outlined above.

2. The most current documentation of the standpipe testing is dated 3/19/08. As stated above, this is a 5-year test and is approximately 11-months past due at this time.
Note: The facility produced a contract dated 12/12/13 for testing of the stand pipes. This test has not occurred as of the survey date.

3. The last documented 3-year full flow testing of the Floating Building dry-pipe system is dated 12/8/09.
Note: This was verified by viewing the attached inspection tags to the valves.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A. NFPA 90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years.
NOTE: The Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC announced a Categorical Waiver for Hospitals to apply the NFPA 6-year testing interval for fire and smoke dampers in Hospital heating and ventilating systems, so long as the Hospital ' s testing system conforms to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105.

THE FINDINGS INCLUDE:

While performing the record review of the fire damper inspections on 1/30/14 at approximately 9:00 A.M., it was observed that numerous fire dampers throughout the facility were last inspected/tested in July 2007. As a result, the fire dampers are approximately 6-months past due at this point in time for the 6-year test. In addition, the facility did not present the survey team with a categorical waiver requesting the 2-year extension of the testing of these devices. As a result, the facility is still under the 4-year testing cycle until an approved waiver application is accepted.
Note: The facility is currently in the process of applying for the 6-year testing interval in accordance with S&C 10-04.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.





















16934

A) Based on observations, the facility failed to ensure that HVAC systems are installed in accordance with NFPA 90A. Section 2.3.4.1 requires a service opening to be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within. Section 2.3.8 requires fire dampers to be installed in conformance with the conditions of their listings. Section 3.4.6.2 requires fire dampers, including their sleeves; smoke dampers; and ceiling dampers to be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions. Section 3.4.6.4 requires ducts which pass through walls, floors, or partitions that are required to have a fire resistance rating and where fire dampers are not required, the opening in the construction around the air duct shall (1) Not exceeding a 1-in. average clearance on all sides, and (2) Shall be filled solid with an approved material capable of preventing the passage of flame and hot gases.

THE FINDINGS INCLUDE:

1. Observations while touring the facility on 1/29/14 revealed there was no evidence of a fire damper in the 6" diameter duct penetrating the two hour barrier above the cross corridor doors F3.7 at corridors C330 and C331. In addition to the installation of a fire damper, an access panel should be installed.

B) Based on observations and confirmed by staff, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A. NFPA 90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years.
NOTE: The Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC announced a Categorical Waiver for Hospitals to apply the NFPA 6-year testing interval for fire and smoke dampers in Hospital heating and ventilating systems, so long as the Hospital ' s testing system conforms to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105.

THE FINDINGS INCLUDE:

2) While performing the record review of the fire damper inspections on 1/30/14 at approximately 9:00 A.M., it was observed that numerous fire dampers throughout the facility were last inspected/tested in July 2007. As a result, the fire dampers are approximately 6-months past due at this point in time for the 6-year test. In addition, the facility did not present the survey team with a categorical waiver requesting the 2-year extension of the testing of these devices. As a result, the facility is still under the 4-year testing cycle until an approved waiver application is accepted.
Note: The facility is currently in the process of applying for the 6-year testing interval in accordance with S&C 10-04.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observation, the facility failed to assure compliance with chapter 19. Section 19.3.1.1 requires any vertical opening to be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall not have less than a 1-hour fire resistance. NFPA 82 , section 3-2.4.3 states that every service opening shall be in a room or compartment that is separated from other parts of the building by a wall, partition, floor, and floor-ceiling assemblies have a fire resistance rating of not less than the required rating of the chute enclosure. NFPA 82, section 3-2.6.1 states that linen chutes shall terminate in a room or discharge directly into a room having a minimum fire resistance rating not less than that specified for the chute.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/30/14 through 2/3/14 revealed that:

The Floating Building's street level Trash Chute Discharge Room ( identified as #064B) is not enclosed as required, due to the following:

1. The single leaf 1-1/2 hour corridor door, between 064B and corridor C006, does not close and latch when released from the open position. The door's latch mechanism doesn ' t overcome the resistance at the strike plate.

2. It was observed on 1/30/14 that the set of double doors between 064A and 064B had a wash down hose hung over the door preventing the door from closing and latching. When the hose was removed, the inactive leaf did not engage in the header. Therefore, the doors were not able to properly latch as required in their frame.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

A. Based on observation, confirmed by staff, and reported on the 10/11/13 North Atlantic Fire & Safety Equipment Inc. the facility was not in compliance with Section 39.5.1 which requires utilities to be in compliance with Section 9.1. Section 9.1.2 requires electrical wring and equipment to be in accordance with NFPA 70, National Electric Code. NFPA 70, Section 110-26. Spaces About Electrical Equipment requires sufficient access and working space to be be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment.

THE FINDINGS INCLUDE:1. The facility is not in compliance with NFPA 70, Section 110-26 as a result of the evidence of water staining an approximate 3' x 3' area of the gypsum ceiling in the electric room, located in the rear means of egress which leads to the courtyard. A cause of the leaking is identified on the 10/11/13 North Atlantic Fire & Safety Equipment Inc report for the quartely inspection of the sprinkler system. The report states that water runs into the vent for the Electric Room when conducting the water flow test through the inspectors tests valve. This could cause an electric hazard.

B. Based on observation and documentation review, the facility failed to test and maintain records of the tests for the back-up batteries to the fire alarm system. LSC Section 4.6.12.1 requires that whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA #72, Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:1. Documenation provided did not substantiate a 30 minute battery discharge test was conducted annually and a load voltage test of the batteries was conducted semi-annually. In addition, the batteries in the fire alarm panel are dated 9/29/09 which is greater than the 4 years replacement requirement.


C. Based on observations and confirmed by staff on the morning of 1/30/14, illumination of Means of Egress was not in compliance with Section 7.8. Section 7.8.1.2 requires illumination of means of egress to be continuous during the time that the conditions of occupancy require that the means of egress be available for use.
THE FINDINGS INCLUDE:

1. The corridor which leads into the courtyard, at the rear of the program area, is equipped with lighting that can be manually switched off. This does not meet the requirement of Section 7-8.1.2 which requires illumination of means of egress to be continuous during the hours of operation.

This was acknowledged by facility personnel during the tour an by the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that corridor doors are maintained as required.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/24/14 through 2/3/14 revealed that the corridor door's latch mechanism to room #202 on the Pratt/Farnsworth second floor unit does not close and latch in it's frame. The door hinge has pulled from the door frame causing the door to hit the door frame when attempting to close.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that corridor doors are maintained as required.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/24/14 through 2/3/14 revealed that the corridor door's latch mechanism to room #202 on the Pratt/Farnsworth second floor unit does not close and latch in it's frame. The door hinge has pulled from the door frame causing the door to hit the door frame when attempting to close.


This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that corridor doors are maintained as required.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/27/14 through 2/3/14 revealed that:

1. The corridor doors identified as F6.11 & F6.19 in the Floating Building's sixth floor level PICU Suite have a space between the door leaf(s) greater than 1/4 "at the door's meeting edges. This is greater than the allowable 1/8".

2. The corridor door identified as F4.10, in the Floating Building's fourth floor level, has a broken door coordinator impeding the door from closing properly when released from the open position.

3. The seventh floor level corridor door, identified as F-7.9 , have ½ " diameter holes through the door slab where magnetic locking plates were removed. It also has a ¼ " gap at the doors meeting edges.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

A. Based on observations the facility failed to ensure that corridor doors protecting openings in corridor walls are constructed as required. NFPA 101 Life Safety Code 2000 Edition Chapter 19.3.6.4 prohibits transfer grilles, regardless of whether they are protected by fusible link operated dampers, to be used in corridor walls and doors. Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets and similar auxiliary spaces that do not contain flammable or combustible materials shall be permitted to have ventilating louvers or to be undercut.

THE FINDINGS INCLUDE:

1. Observations while touring the facility on the morning of 1/27/13, at approximately 11:30 am, revealed the existence of a 2' x 2' transfer grille in the door of Room 249A. Room 249A is located off an exit corridor on the second floor of the Proger building and is used for the storage of non flammable, non oxidizing inert medical gases (carbon dioxide and liquid nitrogen).

Note: The room is of the proper fire resistive rating for the storage of the above-mentioned medical gases.


B. Doors leading to suites of room must comply with Chapter 19, Section 19.3.6.3.2 of the 2000 Edition of NFPA 101 Life Safety Code. Section 19.3.6.3.2 states corridor doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

THE FINDINGS INCLUDE:

1. Observations while touring the facility during the afternoon of 1/30/14, at approximately 2:15 pm, revealed that the inactive leaf of the entrance doors to the Nuclear Imaging Suite is equipped with manual latching flush bolts. In order for the active leaf to positively latch on a consistent basis the inactive leaf must be equipped with an automatic latching flush bolt.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observations, the facility failed to assure that vertical shafts are enclosed as required.

THE FINDINGS INCLUDE:

Observations while touring the Floating Building's eighth floor level on 1/28/14 revealed that the walls enclosing the vertical H.V.A.C. shaft are open to the adjacent mechanical space. This H.V.A.C. shaft, which was identified as having a 2 hour rating on plans dated 12/13/13, is open due to unsealed gypsum wallboard (GWB) penetrations around the approximate 16" diameter duct behind the service elevator, E003.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations the facility failed to ensure that stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with NFPA 101 Life Safety Code 2000 Edition, Chapter 8, Section 8.2.5.6.

Section 8.2.5.6. states unless prohibited by Chapters 12 through 42, an atrium shall be permitted, provided that the following conditions are met:
(1) In other than existing, previously approved atria, atriums are separated from the adjacent spaces by fire barriers with not less than a 1-hour fire resistance rating with opening protectives for corridor walls. (See 8.2.3.2.3.1(2), Exception No. 1.)
Exception No. 1: Any number of levels of the building shall be permitted to open directly to the atrium without enclosure based on the results of the engineering analysis required in 8.2.5.6(5).
Exception No. 2*: Glass walls and inoperable windows shall be permitted in lieu of the fire barriers where automatic sprinklers are spaced along both sides of the glass wall and the inoperable window at intervals not to exceed 6 ft (1.8 m). The automatic sprinklers shall be located at a distance from the glass not to exceed 1 ft (0.3 m) and shall be arranged so that the entire surface of the glass is wet upon operation of the sprinklers. The glass shall be tempered, wired, or laminated glass held in place by a gasket system that allows the glass framing system to deflect without breaking (loading) the glass before the sprinklers operate. Automatic sprinklers shall not be required on the atrium side of the glass wall and the inoperable windows where there is no walkway or other floor area on the atrium side above the main floor level. Doors in such walls shall be glass or other material that resists the passage of smoke. Doors shall be self-closing or automatic-closing upon detection of smoke.

THE FINDING INCLUDES:

Observations while conducting the facility tour on the afternoon of 1/27/14, at approximately 1:15 pm, revealed the set of glass doors to the entrance of the pharmacy, located on the third floor of the Proger building, are lacking self-closing devices and were being held open with magnetic devices which are not tied into the smoke detection system. (The glass doors are part of a tempered glass partition wall with automatic sprinklers positioned on both sides of the wall at spaced intervals in accordance with regulations. )

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observations, the facility failed to assure that smoke detectors for door release are installed in accordance with NFPA #72. Where the depth of the wall section above the door is less than 24 inches Section 2.10.6.2.5.1.1 and Figure 2.10.6.2.5.1.1 require one smoke detector to be placed within 5 feet of the door and not less than 12 inches from the door. NOTE: If the depth of the wall section above the door is more than 24 inches an additional smoke detector may be required.

THE FINDINGS INCLUDE:

Observations while touring the Floating Building's seventh floor level on 1/27/14 and 1/28/14 revealed that there are no smoke detectors installed on or near the doors separating the Floating Building and the Prodger Building. There is approximately 11 feet of wall above each side of the door.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations, the facility failed to assure that smoke detectors for door release are installed in accordance with NFPA #72. Where the depth of the wall section above the door is less than 24 inches Section 2.10.6.2.5.1.1 requires one smoke detector to be placed within 5 feet of the door and not less than 12 inches from the door.
Section 2-10.6.5.1.2* states the following:
If the depth of wall section above the door is greater than 24 in. (610 mm), two ceiling-mounted detectors shall be required, one on each side of the doorway.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 1/29/14, at approximately 2:30 pm, revealed that the set of doors which are incorporated into the rated barrier separating the Atrium from the eighth floor of the Proger building are deficient. On the Atrium side, the wall section above the doors is approximately forty-eight inches in depth and is without a smoke detection device as required for door release.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

While performing the tour of the Pratt Building seventh floor level on 1/29/14, it was observed that the corridor door to the Soiled Utility Room, labeled #726, is not equipped with a closing mechanism. When released from the open position, the door would not automatically close and latch into the door frame as required.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

While performing the tour of the Floating Building operating rooms on 1/29/14 at approximately 6:45 A.M., it was observed that the door to the dirty holding room (#529) is not equipped with a latching mechanism. When the door was tested for proper operation, the door would not close & latch into the door frame as required.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

B. Based on observations, the facility failed to assure that hazardous areas are enclosed as required. Section 19.3.2.1 requires the doors to rooms or spaces larger than 50 sq. ft. including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction, to be self-closing.

THE FINDINGS INCLUDE:

1. Observations while touring the facility on the morning of 1/28/14, at approximately 10:25 A.M., revealed that the door to Room 403, located on the fourth floor of the Proger building, is not self-closing. Room 403 is greater than fifty square feet in size and is used for the storage of large quantities of combustible supplies. Such conditions require the door to be self-closing.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observations, the facility failed to ensure that exit stairways are enclosed as required.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/27/14 through 2/3/14 revealed that:

1. Stair #2, located on the Floating Building's eighth floor level, is not constructed as required. A 1/4" space along the stair's meeting edge at the ceiling, adjacent to the 4 " x 8 " I-beam, leaves the stair open to the adjoining mechanical space.

2. The Floating Building's eighth floor level stair door from the playroom, connecting the playroom to the seventh floor level medical unit, is not equipped with a door rating label. Therefore, the separation between the eighth and seventh floor level is less than required.

3. The Floating Building's fourth floor level stair #3 (S003) enclosure has an unsealed space around the sprinkler pipe penetration which leads into the storage room (408S).

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations, the facility fail to maintain the requires means of egress. NFPA 101, Section 7-1.10.1 requires means of egress to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.2.1.6.1 states approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42. Section 7.2.1.6.1 (c)states an irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door.

THE FINDINGS INCLUDE:


While performing a building tour of the third floor of the North Building on 1/28/14 at approximately 3:00 P.M., it was revealed that the door to the stairwell has a delayed egress type look that must release 15 seconds after a force is applied on the door's panic bar releasing device. A test was performed by the surveyor by putting a force on the door's panic bar releasing device. The door lock did not release after the 15 second time period allowed by the code.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observation, the facility was not in compliance with Section 19.2.5. Section 19.2.5.7 allows suites of rooms, other than patient sleeping rooms, to be allowed if the suite does not exceed 10,000 ft2 (930 m2). If the treatment suite were to exceed 10,000 sq. ft. in area, it would cease to qualify for the suite provisions of 18/19.2.5. As such, this group of rooms and aisles would be required to comply with 18/19.2.3.3 relative to exit access minimum width and 18/19.3.6 relative to corridor walls and doors.

THE FINDINGS INCLUDE:

Based on observations and Life Safety Drawings dated 12/13/2013, the Neonatal Intensive Care Unit (NICU) Suite D2-B, located on the 2nd floor of North, is 14,366 ft2 which is not in compliance with Section 19-2.5.7.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observation, the facility was not in compliance with Section 19.2.5. Section 19.2.5.7 allows suites of rooms, other than patient sleeping rooms, to be allowed if the suite does not exceed 10,000 ft2 (930 m2). If the treatment suite were to exceed 10,000 sq. ft. in area, it would cease to qualify for the suite provisions of 18/19.2.5. As such, this group of rooms and aisles would be required to comply with 18/19.2.3.3 relative to exit access minimum width and 18/19.3.6 relative to corridor walls and doors.

THE FINDINGS INCLUDE:

Based on observations and Life Safety Drawings dated 12/13/2013, the Operating Room Suite F5-A, located on the 5th floor of Floating, is 22,449 ft2 which is not in compliance with Section 19-2.5.7.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

The facility was not in compliance with Section 19.2.5.6 which states suites of sleeping rooms shall not exceed 5,000 ft2.

THE FINDINGS INCLUDE:

Based on observations and Life Safety Drawings dated 12/16/2013, the Surgical Intensive Care Unit located on the fifth floor of the Proger building contains 5,623 ft2. The unit is 623 ft2 in excess of the maximum allowable size.

The finding was confirmed by the Director of Facilities Management during the exit conference.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground.

THE FINDINGS INCLUDE:

1. While performing a building tour of the seventh floor of the North Building on 1/27/14 at approximately 3:00 P.M., it was revealed that the set of ninety minute fire rated doors D7.8, accessing the horizontal exit separating the seventh floor from the Atrium stairway, are rubbing against the frame prohibiting the doors from latching properly.

2. While performing a building tour of the sixth floor of the North Building on 1/27/14 at approximately 4:00 P.M., it was revealed that the set of ninety minute fire rated doors D6.7, accessing the horizontal exit separating the seventh floor from the Atrium stairway, has an air balancing issue between the North and Atrium buildings that will not allow the doors to latch.

3. While performing a building tour of the fifth floor of the North Building on 1/28/14 at approximately 11:00 A.M., it was revealed that the set of rated doors D5.6, accessing the horizontal exit separating the seventh floor from the Floating building stairway, are labeled as forty five minute fire doors and not the required ninety minutes.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/27/14 through 2/3/14 revealed that the Floating Building's third floor level corridors C309 and C330, which lead to the Biewend Building and the garage, are equipped with light switches accessible to staff, patients and visitors. When these switches were tested for operation, entire corridors were put into complete darkness.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/29/14 that the Pratt Building's eighth floor level corridor to stair #2 is equipped with light switches accessible to staff, patients and visitors. When these switches were tested for operation, the entire corridors were put into complete darkness.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on staff interview, the facility failed to ensure compliance with section 7.9.2.3 which refers to NFPA 110 (Standards for Emergency Power Systems). NFPA 110, Section 6-4.2 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations. Section 6-4.3 requires load tests of generator sets to include a complete cold start.

THE FINDINGS INCLUDE:

Based on staff interview, 30 minute generator load tests are being conducted for the Courtyard emergency generator; however, these tests are not conducted from a cold start as required by NFPA 110, Section 6-4.3.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

A review of fire drill reports conducted on the afternoon of 1/29/14, at approximately 2:45 pm, revealed fire drills are not conducted as required. NFPA 101 Life Safety Code 2000 Edition Section 19.7.1.2 states fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

THE FINDINGS INCLUDE:

According to the fire drill documentation provided by the facility's Emergency Management Officer on the afternoon of 1/29/14, the following deficiencies were noted:

1. There is no record of a second shift ( 3 pm-11 pm ) fire drill being conducted for the fourth quarter of 2013.

2. There is no record of a third shift (11 pm-7 am ) fire drill being conducted for the second quarter of 2013.

3. Fire drills between the hours of 6:00 am and 9:00 pm are being conducted without the transmission of a fire alarm signal.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.


31165

A review of fire drill reports conducted on the afternoon of 1/29/14, at approximately 2:45 pm, revealed fire drills are not conducted as required. NFPA 101 Life Safety Code 2000 Edition Section 19.7.1.2 states fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

THE FINDINGS INCLUDE:

According to the fire drill documentation provided by the facility's Emergency Management Officer on the afternoon of 1/29/14, the following deficiencies were noted:

1. There is no record of a second shift ( 3 pm-11 pm ) fire drill being conducted for the fourth quarter of 2013.

2. There is no record of a third shift (11 pm-7 am ) fire drill being conducted for the second quarter of 2013.

3. Fire drills between the hours of 6:00 am and 9:00 pm are being conducted without the transmission of a fire alarm signal.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

A review of fire drill reports conducted on the afternoon of 1/29/14, at approximately 2:45 pm, revealed fire drills are not conducted as required. NFPA 101 Life Safety Code 2000 Edition Section 19.7.1.2 states fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

The Findings Include:

According to the fire drill documentation provided by the facilities Emergency Management Officer on the afternoon of 1/29/14, the following deficiencies were noted:

1. There is no record of a second shift ( 3 pm-11 pm) fire drill being conducted for the fourth quarter of 2013.

2. There is no record of a third shift (11 pm-7 am) fire drill being conducted for the second quarter of 2013.

3. Fire drills between the hours of 6:00 am and 9:00 pm are being conducted without the transmission of a fire alarm signal.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.
NFPA 92B section 5.4.1 states that during the life of the building, maintenance is essential to ensure that the smoke management system will perform its intended function under fire conditions. Proper maintenance of the system should, as a minimum, include the periodic testing of all equipment, such as initiating devices, fans, dampers, controls, doors, and windows. The equipment should be maintained in accordance with the manufacturer ' s recommendations. (See NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, for suggested maintenance practices.)
Section 5.4.2 states the periodic tests should determine that the installed systems will continue to operate in accordance with the approved design. It is preferable to include in the tests both the measurements of airflow quantities and the pressure differentials at the following locations:
(1) Across smoke barrier openings
(2) At the air makeup supplies
(3) At smoke exhaust equipment
All data points should coincide with the acceptance test location to facilitate comparison measurements.

Section 5.4.3 states the system should be tested at least semiannually by persons who are thoroughly knowledgeable in the operation, testing, and maintenance of the systems. The results of the tests should be documented in the operations and maintenance log and made available for inspection. The smoke management system should be operated for each sequence in the current design criteria. The operation of the correct outputs for each given input should be observed. Tests, if applicable, should also be conducted under standby power.

THE FINDINGS INCLUDE:

While performing the record review of the fire alarm system on 1/29/14 at approximately 9:00 A.M., it was observed that the facility has no records documenting testing of the smoke evacuation system. The facility contacted the fire alarm vendor at this time to secure any records for testing of this system. During the morning of 2/3/14 at approximately 8:00 A.M., it was revealed that no testing/inspections of the smoke evacuation system has been conducted in recent years. The facility in conjunction with the fire alarm vendor have no records of any testing of this system.

This was acknowledged by the Director of Engineering during the exit interview.

Based on record review and confirmed by staff, the facility failed to ensure compliance with NFPA #72. Section 7-3.2.1 states smoke detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

THE FINDING INCLUDE:

While performing the record review of the fire alarm system on 1/29/14 at approximately 9:00 A.M., it was observed that the sensitivity inspection/testing forms dated 12/14/13 for the Pratt & Farnsworth Buildings were observed as being blank. Although the individual devices are identified on the forms, the devices are not listed as passing or failing the required test.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on record review and confirmed by staff, the facility failed to ensure compliance with NFPA #72. Section 7-3.2.1 states smoke detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

THE FINDING INCLUDE:

While performing the record review of the fire alarm system on 1/29/14 at approximately 9:00 A.M., it was observed that the sensitivity inspection/testing forms dated November 2013 indicate that approximately 75% of the smoke detectors located in the Floating Building failed the sensitivity test.

Note: It was stated by staff that the facility is implementing a plan for replacing all of the smoke detectors within the building.

This was acknowledged by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are properly supervised. Section 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

THE FINDINGS INCLUDE:

While viewing the sprinkler control valves on 1/30/14 at 10:00 A.M. it was observed that not all sprinkler valves are electronically supervised as required. The dry system OS&Y valve located on the street level of the Floating Building is not equipped with a supervisory device. It was observed that a new butterfly valve was installed above the existing OS&Y valve. Upon closer examination, it was observed that the supervisory switch was moved from the existing OS&Y valve to the new valve. However, the existing valve is still functional and has the capability of shutting the water supply off to the sprinkler system, therefore requiring supervision.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Section 5-3.2.1 states a weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.

Section 5-3.2.4 states the pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running.

Section 5-3.2.4.1 outlines the Pump System Procedure and what must be documented.
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.

Section 5-3.2.4.2 outlines the Electrical System Procedure and what must be documented.
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic stop controllers).

Section 3-3.1.1 states a flow test shall be conducted at the hydraulically most remote hose connection of each zone of a standpipe system to verify the water supply still adequately provides the design pressure at the required flow. Where a flow test of the hydraulically most remote outlet(s) is not practical, the authority having jurisdiction shall be consulted for the appropriate location for the test. A flow test shall be conducted every 5 years.

Section 9-4.4.2.2.1 states every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service. During those years when full flow testing in accordance with 9-4.4.2.2.1 is not required, each dry pipe valve shall be trip tested with the control valve partially open. Section 9-4.4.2.5 states a tag or card showing the date on which the dry pipe valve was last tripped and showing the name of the person and organization conducting the test shall be attached to the valve. Separate records of initial air and water pressure, tripping air pressure, and dry pipe valve operating condition shall be maintained on the premises for comparison with previous test results. Records of tripping time also shall be maintained for full flow trip tests.

THE FINDINGS INCLUDE:

While performing the record review of the sprinkler system on 1/29/14 at approximately 11:00 A.M., the following items were observed regarding the sprinkler systems:

1. The weekly fire pump test/inspection forms provided by the facility state the fire pumps are run for 10-minutes weekly while only documenting the suction & discharge pressures. There is no other information provided regarding the other testing criteria as outlined above.

2. The most current documentation of the standpipe testing is dated 3/19/08. As stated above, this is a 5-year test and is approximately 11-months past due at this time.
Note: The facility produced a contract dated 12/12/13 for testing of the stand pipes. This test has not occurred as of the survey date.

3. The last documented 3-year full flow testing of the Floating Building dry-pipe system is dated 12/8/09.
Note: This was verified by viewing the attached inspection tags to the valves.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Section 5-3.2.1 states a weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.

Section 5-3.2.4 states the pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running.

Section 5-3.2.4.1 outlines the Pump System Procedure and what must be documented.
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.

Section 5-3.2.4.2 outlines the Electrical System Procedure and what must be documented.
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic stop controllers).

Section 3-3.1.1 states a flow test shall be conducted at the hydraulically most remote hose connection of each zone of a standpipe system to verify the water supply still adequately provides the design pressure at the required flow. Where a flow test of the hydraulically most remote outlet(s) is not practical, the authority having jurisdiction shall be consulted for the appropriate location for the test. A flow test shall be conducted every 5 years.

THE FINDINGS INCLUDE:


While performing the record review of the sprinkler system on 1/29/14 at approximately 11:00 A.M., the following items were observed regarding the sprinkler systems:

1. The weekly fire pump test/inspection forms provided by the facility state the fire pump is run for 10-minutes weekly while only documenting the suction & discharge pressures. There is no other information provided regarding the other testing criteria as outlined above.

2. The most current documentation of the standpipe testing is dated 3/19/08. As stated above, this is a 5-year test and is approximately 11-months past due at this time.
Note: The facility produced a contract dated 12/12/13 for testing of the stand pipes. This test has not occurred as of the survey date.

3. The last documented 3-year full flow testing of North & South Building dry-pipe system is dated 12/11/09.
Note: This was verified by viewing the attached inspection tags to the valves.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A. NFPA 90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years.
NOTE: The Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC announced a Categorical Waiver for Hospitals to apply the NFPA 6-year testing interval for fire and smoke dampers in Hospital heating and ventilating systems, so long as the Hospital ' s testing system conforms to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105.

THE FINDINGS INCLUDE:

While performing the record review of the fire damper inspections on 1/30/14 at approximately 9:00 A.M., it was observed that numerous fire dampers throughout the facility were last inspected/tested in July 2007. As a result, the fire dampers are approximately 6-months past due at this point in time for the 6-year test. In addition, the facility did not present the survey team with a categorical waiver requesting the 2-year extension of the testing of these devices. As a result, the facility is still under the 4-year testing cycle until an approved waiver application is accepted.
Note: The facility is currently in the process of applying for the 6-year testing interval in accordance with S&C 10-04.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.





















16934

A) Based on observations, the facility failed to ensure that HVAC systems are installed in accordance with NFPA 90A. Section 2.3.4.1 requires a service opening to be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within. Section 2.3.8 requires fire dampers to be installed in conformance with the conditions of their listings. Section 3.4.6.2 requires fire dampers, including their sleeves; smoke dampers; and ceiling dampers to be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions. Section 3.4.6.4 requires ducts which pass through walls, floors, or partitions that are required to have a fire resistance rating and where fire dampers are not required, the opening in the construction around the air duct shall (1) Not exceeding a 1-in. average clearance on all sides, and (2) Shall be filled solid with an approved material capable of preventing the passage of flame and hot gases.

THE FINDINGS INCLUDE:

1. Observations while touring the facility on 1/29/14 revealed there was no evidence of a fire damper in the 6" diameter duct penetrating the two hour barrier above the cross corridor doors F3.7 at corridors C330 and C331. In addition to the installation of a fire damper, an access panel should be installed.

B) Based on observations and confirmed by staff, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A. NFPA 90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years.
NOTE: The Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC announced a Categorical Waiver for Hospitals to apply the NFPA 6-year testing interval for fire and smoke dampers in Hospital heating and ventilating systems, so long as the Hospital ' s testing system conforms to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105.

THE FINDINGS INCLUDE:

2) While performing the record review of the fire damper inspections on 1/30/14 at approximately 9:00 A.M., it was observed that numerous fire dampers throughout the facility were last inspected/tested in July 2007. As a result, the fire dampers are approximately 6-months past due at this point in time for the 6-year test. In addition, the facility did not present the survey team with a categorical waiver requesting the 2-year extension of the testing of these devices. As a result, the facility is still under the 4-year testing cycle until an approved waiver application is accepted.
Note: The facility is currently in the process of applying for the 6-year testing interval in accordance with S&C 10-04.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A. NFPA 90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years.
NOTE: The Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC announced a Categorical Waiver for Hospitals to apply the NFPA 6-year testing interval for fire and smoke dampers in Hospital heating and ventilating systems, so long as the Hospital ' s testing system conforms to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105.

THE FINDINGS INCLUDE:

While performing the record review of the fire damper inspections on 1/30/14 at approximately 9:00 A.M., it was observed that numerous fire dampers throughout the facility were last inspected/tested in July 2007. As a result, the fire dampers are approximately 6-months past due at this point in time for the 6-year test. In addition, the facility did not present the survey team with a categorical waiver requesting the 2-year extension of the testing of these devices. As a result, the facility is still under the 4-year testing cycle until an approved waiver application is accepted.
Note: The facility is currently in the process of applying for the 6-year testing interval in accordance with S&C 10-04.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

Based on observation, the facility failed to assure compliance with chapter 19. Section 19.3.1.1 requires any vertical opening to be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall not have less than a 1-hour fire resistance. NFPA 82 , section 3-2.4.3 states that every service opening shall be in a room or compartment that is separated from other parts of the building by a wall, partition, floor, and floor-ceiling assemblies have a fire resistance rating of not less than the required rating of the chute enclosure. NFPA 82, section 3-2.6.1 states that linen chutes shall terminate in a room or discharge directly into a room having a minimum fire resistance rating not less than that specified for the chute.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/30/14 through 2/3/14 revealed that:

The Floating Building's street level Trash Chute Discharge Room ( identified as #064B) is not enclosed as required, due to the following:

1. The single leaf 1-1/2 hour corridor door, between 064B and corridor C006, does not close and latch when released from the open position. The door's latch mechanism doesn ' t overcome the resistance at the strike plate.

2. It was observed on 1/30/14 that the set of double doors between 064A and 064B had a wash down hose hung over the door preventing the door from closing and latching. When the hose was removed, the inactive leaf did not engage in the header. Therefore, the doors were not able to properly latch as required in their frame.

This was acknowledged by facility personnel during the survey and by the Director of Engineering during the exit interview.

A. Based on observation, confirmed by staff, and reported on the 10/11/13 North Atlantic Fire & Safety Equipment Inc. the facility was not in compliance with Section 39.5.1 which requires utilities to be in compliance with Section 9.1. Section 9.1.2 requires electrical wring and equipment to be in accordance with NFPA 70, National Electric Code. NFPA 70, Section 110-26. Spaces About Electrical Equipment requires sufficient access and working space to be be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment.

THE FINDINGS INCLUDE:1. The facility is not in compliance with NFPA 70, Section 110-26 as a result of the evidence of water staining an approximate 3' x 3' area of the gypsum ceiling in the electric room, located in the rear means of egress which leads to the courtyard. A cause of the leaking is identified on the 10/11/13 North Atlantic Fire & Safety Equipment Inc report for the quartely inspection of the sprinkler system. The report states that water runs into the vent for the Electric Room when conducting the water flow test through the inspectors tests valve. This could cause an electric hazard.

B. Based on observation and documentation review, the facility failed to test and maintain records of the tests for the back-up batteries to the fire alarm system. LSC Section 4.6.12.1 requires that whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA #72, Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:1. Documenation provided did not substantiate a 30 minute battery discharge test was conducted annually and a load voltage test of the batteries was conducted semi-annually. In addition, the batteries in the fire alarm panel are dated 9/29/09 which is greater than the 4 years replacement requirement.


C. Based on observations and confirmed by staff on the morning of 1/30/14, illumination of Means of Egress was not in compliance with Section 7.8. Section 7.8.1.2 requires illumination of means of egress to be continuous during the time that the conditions of occupancy require that the means of egress be available for use.
THE FINDINGS INCLUDE:

1. The corridor which leads into the courtyard, at the rear of the program area, is equipped with lighting that can be manually switched off. This does not meet the requirement of Section 7-8.1.2 which requires illumination of means of egress to be continuous during the hours of operation.

This was acknowledged by facility personnel during the tour an by the Director of Engineering during the exit interview process.