HospitalInspections.org

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Based on observations and staff interviews, the facility failed to ensure that if a building containing a healthcare occupancy has a common wall with a non-conforming building that the common wall has at least a two (2) hour fire resistance rating. Specific reference is made to the two (2) hour fire barrier walls that separate the non-conforming "1955" Building from the "1977" and "2001" Buildings.

Findings:

On 09/29/14 at 11:05AM an unsealed cable penetration was noted above a set of cross-corridor fire doors in the two (2) hour combination fire / smoke barrier wall that separates the 1st Floor of the "1955" Building from the 1st Floor of the "1977" Building. As per concurrent interview with the facility's Director of Engineering, he will have this penetration sealed immediately.

On 09/30/14 at 10:10AM, the top-of-wall assembly of the two (2) hour fire barrier that separates the 1st Floor of the "1955" Building from the "2001" Building (vicinity of the "1955" Building B-Wing Decontamination Equipment Storage Room and Linen Storage Room) was not sealed with firestopping. As per concurrent interview with the facility's Director of Engineering, he will have this deficiency corrected immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.1.1.4.1, 8.2.3

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interviews, the facility failed to ensure that corridors were separated from all other areas, including Patient Areas, by partitions complying with Sections 19.3.6.2 through 19.3.6.5. Specifically, Section 19.3.6.2.2 requires that corridor walls form a barrier to prevent the transfer of smoke.

Findings:

On 09/29/14 at 1:30PM an approximately twelve (12) inch by twelve (12) inch non-ducted air transfer grill (opening) was noted between an Exit access corridor wall and the 1st Floor Physical Therapy Treatment Area in the "1955" Building. As per concurrent interview with the facility's Director of Engineering, he will have this unprotected air transfer opening sealed immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.6.2.2

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interview, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 19.3.6.3.2 requires that corridor doors in Existing Health Care Occupancies be provided with a means suitable for keeping the door closed that is acceptable to the Authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings:

On 10/01/14 at 10:57AM the inactive leaf to a set of double doors to Communication Room S137 in the S-Wing of the "2001" Building was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire. As per concurrent interview with the facility's Director of Engineering, he has already initiated a facility-wide project to replace all of the manual flush bolts on the inactive leaves of doors with approved automatic flush bolts. He said that the project should be completed in the very near future.

On 10/01/14 at 11:42AM the inactive leaf to a set of double doors to Electrical Closet A147 in the 1st Floor of the A-Wing in the "2001" Building was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire.

On 10/01/14 at 12:34PM the inactive leaf to a set of double doors to Electrical Closet A131A in the 1st Floor of the A-Wing in the "2001" Building was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.6.3.2

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interview, the facility failed to ensure that all vertical penetrations of fire barriers were enclosed with construction having at least a one (1) hour fire resistance rating.

Findings:

On 09/29/14 at 11:08AM an unsealed vertical plumbing penetration was noted inside the floor of the Exit stair into the CCU Wing in the "1977" Building (vicinity of the landing that serves the door to the outside). As per concurrent interview with the facility's Director of Engineering, this penetration will be sealed immediately.

On 09/29/14 at 11:18AM an unsealed vertical cable penetration was noted in the floor of the 1st Floor Respiratory Department Office (near the entrance to the Step-Down Unit) in the "1977" Building. As per concurrent interview with the facility's Director of Engineering, this penetration will be sealed immediately.

On 09/30/14 at 9:46AM an unsealed vertical cable penetration was noted in the floor of the 1st Floor of the old Linen Chute Room "C" Unit in the "1955" Building. As per concurrent interview with the facility's Director of Engineering, this penetration will be sealed immediately

On 09/30/14 at 10:43AM six (6) unsealed plumbing penetrations were noted in the ceiling / floor assembly in the Wing 7 Large Storage Room in the Basement of the "1955" Building. As per concurrent interviews with the facility's Director of Engineering, these penetrations will be sealed immediately.

On 09/30/14 at 11:01AM an unsealed vertical plumbing penetration was noted in the ceiling / floor assembly in the Housekeeping Equipment Room (where the Sprinkler Zone #1 valve is located) in the "1955" Building. As per concurrent interviews with the facility's Director of Engineering, these penetrations will be sealed immediately.

On 10/01/14 at 8:41AM an unsealed vertical plumbing penetration was noted in the ceiling / floor assembly in the Basement Pneumatic Tube Room in the "1955" Building. As per concurrent interview with the facility's Director of Engineering, this penetration will be sealed immediately.

On 10/01/14 at 9:25AM two (2) unsealed cable penetrations and an unsealed plumbing penetration were noted in the Basement-Level enclosure walls of the accessory staircase that serves the Physician On-Call Room in the Basement of the "1955" Building. As per concurrent interview with the facility's Director of Engineering, this penetration will be sealed immediately

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.1.1, 8.2.5

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interview, the facility failed to ensure that doors in smoke barriers were self-closing and kept in the closed position, unless held open by a release device complying with Section 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:

a) The required manual fire alarm system, and

b) Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system, and

c) The automatic sprinkler system.

Findings:

On 09/30/14 at 8:26AM a smoke barrier door (i.e., the door to the Chaplin's Office in a two (2) hour rated combination smoke / fire barrier on the 1st Floor of the "1955" Building was found to be improperly held open by a magnetic hold-open device that was incapable of automatically releasing this door.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.7.7.6, 19.2.2.6, 8.3.4

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interviews, the facility failed to ensure that existing smoke barrier walls were constructed to have at least a one-half (½) hour fire resistance rating.

Findings:

On 09/29/14 at 1:35PM an unsealed cable penetration was noted above a set of fire doors (doors are identified by signage as "G-Wing-4-032") in the two (2) hour rated combination fire / smoke barrier near the Sleep Laboratory Area on the 1st Floor of the "1955" Building. In addition, the damper actuator arm on a fire / smoke damper in a duct that penetrates the above-mentioned fire / smoke barrier wall was found to be in disrepair (broken) and the duct was found to have been sealed with a firestopping material (caulk) rather than by metal angles. Firestopping material may, when exposed to the heat of a fire, expand and could crush the duct and prevent the fire/smoke damper within the duct from operating properly.

On 09/29/14 at 2:17PM two (2) unsealed cable penetrations were noted in a two (2) hour combination fire / smoke barrier near the MRI Suite and Wound Care Unit on the 1st Floor of the "1955" Building.

On 09/30/14 at 8:30AM a wall-joint of an approximately six (6) inch long section of a soffit (above cross-corridor door openings) in the two (2) hour combination fire / smoke barrier near the Chaplin's Office and the Waiting Room on the 1st Floor of the "1955" Building was sealed with non-fire resistance rated materials (e.g., joint compound and sheetrock tape) rather than approved firestopping materials.

On the morning of 10/01/14 between 10:39AM and 10:50AM, the following were noted:

- An unsealed cable and beam penetration were noted in a one (1) hour fire resistance rated smoke barrier wall in the Staff Toilet Room located across from Janitor's Closet S135 on the 1st Floor of the S-Wing in the "2001" Building.

- Two (2) duct penetrations of a one (1) hour fire resistance rated smoke barrier wall (above the cross-corridor doors near the Staff Toilet Room and Janitor's Closet S135 on the 1st Floor of the S-Wing in the "2001" Building) that contained a fire / smoke damper were found to have been sealed with a firestopping material (caulk) rather than by metal angles.

- Three (3) duct penetrations of a one (1) hour fire resistance rated smoke barrier wall (above the cross-corridor doors near Patient Room S116 and Soiled Utility Room S133 on the 1st Floor of the S-Wing in the "2001" Building) that contained a fire / smoke damper were found to have been sealed with a firestopping material (caulk) rather than by metal angles.

On the afternoon of 10/01/14 between 12:20PM and 12:47PM the following was noted:

- A duct penetration of a one (1) hour fire resistance rated smoke barrier wall (in a corridor by the entrance to the ED X-Ray Room on the 1st Floor of the A-Wing of the "2001" Building) that contained a fire / smoke damper was found to have been sealed with a firestopping material (caulk) rather than by metal angles.

- A cable penetration in a one (1) hour fire resistance rated smoke barrier wall (in a corridor above the newly constructed storage closet by the entrance to the ED X-Ray Room on the 1st Floor of the A-Wing of the "2001" Building) was found to be sealed with a non-fire resistance rated material (e.g., joint compound).

- An unsealed cable penetration in a one (1) hour fire resistance rated smoke barrier wall was noted above Electrical Closet A131A on the 1st Floor of the A-Wing of the "2001" Building.

- Two (2) unsealed cable and one (1) unsealed plumbing penetrations in a one (1) hour fire resistance rated smoke barrier wall were noted in the vicinity of Pre-Surgical Testing Room II on the 1st Floor of the A-Wing of the "2001" Building.

- A partially sealed plumbing penetration was noted in a one (1) hour fire resistance rated smoke barrier wall above a set of cross corridor smoke barrier doors in the vicinity of the Ambulatory Surgery Unit Admitting Area on the 1st Floor of the A-Wing of the "2001" Building.

- An unsealed cable penetration and an unsealed plumbing penetration were noted in a one (1) hour fire resistance rated smoke barrier wall near a Toilet Room by the Ambulatory Surgery Unit Admitting Area on the 1st Floor of the A-Wing of the "2001" Building.

On the afternoon of 10/01/14 between 2:22PM and 3:00PM, the following was noted:

- A duct penetration of a one (1) hour fire resistance rated smoke barrier wall (above the cross-corridor doors near Soiled Utility Room A201 on the 2nd Floor of the A-Wing in the "2001" Building) that contained a fire / smoke damper was found to have been sealed with a firestopping material (caulk) rather than by metal angles.

- Two (2) unsealed cable penetrations in a one (1) hour fire resistance rated smoke barrier wall were noted in the vicinity of Communications Closet A244B on the 2nd Floor of the A-Wing of the "2001" Building. In addition, a duct penetration of the one (1) hour fire resistance rated smoke barrier wall near Communications Closet A244B that contained a fire / smoke damper was found to have been sealed with a firestopping material (caulk) rather than by metal angles.

- Two (2) duct penetrations of a one (1) hour fire resistance rated smoke barrier wall (above the cross-corridor doors near the entrance to the A205 Surgical Holding Area on the 2nd Floor of the A-Wing in the "2001" Building) that contained a fire / smoke damper were found to have been sealed with a firestopping material (caulk) rather than by metal angles.

As per concurrent interviews with the facility's Director of Engineering, all of the penetrations will be sealed with approved firestopping systems as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interview, the facility failed to ensure that smoke barrier doors were self-closing.

Findings:

On 10/01/14 at 12:34PM the active and inactive leaves of a set of smoke barrier doors in Electrical Closet A131A on the 1st Floor of the A-Wing of the "2001" Building were found to lack required self-closing devices. As per concurrent interview with the facility's Director of Engineering, corrective action will be taken as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.7.6

10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based on observations and staff interview, the facility failed to ensure that all newly constructed hazardous areas were enclosed in at least one (1) hour fire resistance rated enclosure walls and that existing hazardous areas were enclosed with smoke resistant walls.

Findings:

a) On 09/29/14 at 2:41PM an old Operating Room that had been converted into a Storage Room on the 1st Floor of the "1955" Building was found to have an approximately twenty-two (22) inch by forty (40) inch non-fire resistance rated vision panel in one (1) of the walls of this room.

b) On 09/30/14 at 9:29AM an unsealed cable penetration was noted in an enclosure wall of a former Patient Room that had been converted into a Storage Room in the B-Wing of the "1955" Building.

c) On 09/30/14 at 9:54AM an old C-Section Room that had been converted into a Storage Room on the 1st Floor of the "1955" Building was found to have an approximately twenty-two (22) inch by forty (40) inch non-fire resistance rated vision panel in one (1) of the walls of this room.

d) On 09/30/14 at 10:54AM three (3) unsealed cable penetrations were noted in the enclosure walls of a former Staff Training Room in the Basement of the "1955" Building that had been converted into a Linen Storage Room.

e) On 09/30/14 at 12:03PM an unsealed plumbing penetration was noted in one (1) of the enclosure walls of the Kitchen Dry Goods Storage Room in the Basement of the "1955" Building.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 18.3.2.1, 19.3.2.1

10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based on observations and staff interview, the facility failed to ensure that all door openings from hazardous areas were protected by self-closing, positive latching doors.

Findings:

On 09/30/14 at 9:56AM the door to a C-Wing File Storage Room in the 1st Floor of the "1955" Building was found to lack a self-closing device.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.2.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations, record reviews and staff interviews, the facility failed to ensure that battery-powered emergency lighting fixtures were maintained in operational condition.

Findings:

On 10/01/14 at 11:26AM a battery-powered light fixture that provides emergency illumination in the Fire Pump Area of the combination Boiler / Mechanical Equipment / Fire Pump Room in the Basement of the A-Wing of the "2001" Building failed to work when tested. As per concurrent interview with the facility's Director of Engineering, he will have the battery replaced in this emergency lighting fixture immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.2.9.2, 7.9

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on staff interview, the facility failed to ensure that all staff were aware of the locations of smoke barrier walls used to separate floors into separate smoke compartments for use during the horizontal evacuation during a fire incident.

Findings:

On 10/01/14 at 2:18PM, interview with the Nurse Manager of the Surgical Unit on the 2nd Floor of the A-Wing in the "2001" Building revealed that she did not know the correct location of the adjacent smoke compartment / area of refuge that would be used in the evacuation of the Operating Room (OR) Suite in the event of a fire. When asked where she would relocate patients to in the event of a fire in one of the Operating Rooms, she said that she would relocate them to the PACU (Post Anesthesia Care Unit) / Recovery Room. The PACU / Recovery Room is located within the same smoke compartment as the Operating Suite and would not be a safe area of refuge for patients and staff in the event of a fire.

Review of the facility's written Fire Plan for the Operating Room (Policy 32.B.0 Hospital Wide Fire Plan dated 10/2013) revealed that the instructions for where to relocate patients in the event of a fire in the Operating Room Suite were very vague and could be confusing to staff. As per interview with the facility's Safety Director on 10/01/14 at 2:22PM, he will update the OR Evacuation Plan so that it provides better clarification on the horizontal evacuation of the space.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.7.1.1, 19.7.2.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observation and staff interview, the facility failed to ensure that smoke detectors were properly maintained.

Findings:

On 09/30/14 at 1:40PM a smoke detector in the Elevator pit for the Elevator cabs in the A-Wing of the "2001" Building was found to have been improperly covered over with a plastic dust cover. As per concurrent interview with the facility's Director of Engineering, he will have this cover removed immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.4.1, 19.3.4.3.1, 9.6, 4.6.12, NFPA 72-1999, National Fire Alarm Code: 7-1.1.1, 7-1.1.2
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1. Based on observations and staff interviews, the facility failed to ensure that automatic sprinkler protection was provided in all required areas.

Findings:

a) On 09/29/14 at 1:25PM a Coat Closet on the 1st Floor Board Room in the "1955" Building was noted to lack required sprinkler protection.

b) On 09/30/14 at 1:25PM the bottom of the Elevator shaft that serves Hydraulic Elevators in the "1955" Building was noted to lack required sprinkler protection.

c) On 10/01/14 at 11:40AM the top of the Stairway shaft of the "Basement" Stair in the A-Wing of the "2001" Building was noted to lack required sprinkler protection.

d) On 10/01/14 at 12:14AM a newly constructed Storage Closet in an Exit access corridor by the Entrance to the Express Care Unit on the 1st Floor of the A-Wing in the "2001" Building was noted to lack required sprinkler protection.

e) On 10/01/14 at 2:10PM the bottom landing of the South Exit Stair (also known as the "OR Stairs") in the A-Wing of the "2001" Building was noted to lack required sprinkler protection.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 19.1.6.1, 9.7.1., NFPA 13-1999 Standard for the Installation of Sprinkler Systems: 5-1.1, 5-13.3.2

10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based on observations, record reviews and staff interviews, the facility failed to ensure that all valves that are capable of affecting the water supply to the automatic sprinkler system were provided with supervisory attachments arranged to sound a supervisory signal to indicate a condition that could impair the satisfactory operation of the sprinkler system.

Findings:

a) On the morning of 10/01/14 it was noted that the facility had at least four (4) Post Indicator Valves (PIVs) and a Reduced Pressure Zone (RPZ) valve that are capable of shutting off water to portions of the sprinkler system and that these valves all lacked supervisory attachments arranged to sound a supervisory signal to indicate a condition that could impair the satisfactory operation of the sprinkler system (e.g., tamper alarms). As per interview with the facility's Director of Engineering on 10/01/14, his staff conducts visual inspections of the sprinkler system PIVs at least three (3) times a day and conducts a visual inspection of the RPZ valve at least once a week to ensure that these valves are kept in the open position.

b) On the morning of 10/02/14 review of Waiver / Equivalency Documents that the facility had been previously issued revealed that the New York State Department of Health had, on 01/15/02, granted a Waiver to the facility for the lack of required supervisory devices on all sprinkler control valves. Approval of this Waiver was contingent on the facility conducting at least monthly visual inspections of the control valves. This deficiency was noted during the 11/07/01 pre-occupancy inspection of the "2001" addition to the facility. Record view also revealed that the Joint Commission had, on 09/05/08, issued an Equivalency for the lack of required supervisory devices on all sprinkler control valves. Approval of this Equivalency was contingent on the facility conducting at least three (3) visual inspections of the Post Indicator Valves. On 10/02/14 at 10:00AM the facility's Director of Engineering and their Corporate Life Safety Director were informed that while they may have been issued a Waiver from the Department of Health and an Equivalency from the Joint Commission, they would need to submit a Waiver request to the Centers for Medicare and Medicaid Services (CMS) for this deficiency.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 19.1.6.1, 9.7.2.1., 9.7.2.2, 9.6.1.4, NFPA 13-1999 Standard for the Installation of Sprinkler Systems, NFPA 72 National Fire Alarm Code

10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based on observations, record review and staff interview, the facility failed to ensure that all fire sprinklers and associated components were maintained in good repair, properly installed, and/or maintained free of foreign material.

The findings include, but are not limited, to the following:

a) During the survey, sprinklers were found to be improperly installed in the following locations:

- On 09/29/14 at 10:43AM in the Clergy Vestment Storage Closet in the Chapel on the 1st Floor of the "1955" Building, an upright sprinkler was improperly installed in the pendent position.

- On 09/29/14 at 11:50AM an escutcheon of a sprinkler in a Toilet Room in the 1st Floor Sleep Lab Room #1 in the "1955" Building was noted to be in disrepair. In addition, the deflector of a sprinkler in Sleeping Suite #1 was found to be located above the suspended ceiling.

- On 09/30/14 at 8:15AM an upright sprinkler was found to be improperly installed in the sidewall position in the interstitial space above the suspended ceiling in the "Radio Room" next to the Board Room on the 1st Floor of the "1955" Building.

- On 09/30/14 at 8:34AM a sidewall sprinkler was found to have been improperly installed upside down in a skylight in the Main Waiting Room of the facility on the 1st Floor of the "1955" Building.

- On 09/30/14 at 9:06AM two (2) pendent sprinkler s were found to be improperly installed in the upright position in the Balance Room on the 1st floor of the "1955" Building.

- On 09/30/14 at 9:46AM a pendant sprinkler was found to have been improperly installed in the sidewall position inside the C-Wing Linen Chute Room in the 1st Floor of the "1955" Building.

- On 09/30/14 at 10:54AM six (6) pendent sprinklers in the interstitial space above the suspended ceiling in the Basement Linen Storage Room (this space had formally been a Training Room) in the "1955" Building were found to have been improperly installed in the upright position.

- On 09/30/14 at 11:20AM the deflector of an upright sprinkler in the exterior loading dock of the "1955" Building had less than one (1) inch of clearance (e.g., approximately three quarters {¾} of an inch)from the ceiling in this area. At least one (1) inch of clearance is required.

- On 09/30/14 at 11:35AM supports for a pipe that served a heat pump in the Main Boiler Room in the Basement of the "1955" Building was found to be improperly attached to overhead sprinkler piping. Sprinkler piping is not permitted to be used to support equipment or systems that are not related to the sprinkler system.

- On 10/01/14 at 9:21AM, the Toilet / Shower Room in the Physicians' On-Call Suite in the Basement of the "1955" Building was noted to lack required sprinkler protection. A pendent sprinkler was found to have been installed above the suspended ceiling in this room but would be unable to provide adequate protection for this room.

- On 09/30/14 at 2:20PM supports for three (3) different light fixtures in the Basement Medical Records Mechanical / Sprinkler Equipment Room the "1977" Building were found to be improperly attached to overhead sprinkler piping. Sprinkler piping is not permitted to be used to support equipment or systems that are not related to the sprinkler system.

On 09/30/14 at 2:38PM five (5) sprinklers in a Basement corridor (the "Respiratory" corridor) in the "1955" Building were noted to have deflectors that were located above the suspended ceiling (e.g., these sprinklers need to be lowered).

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken immediately.

b) During the survey, sprinklers were found to be missing required escutcheon cover plates and/or escutcheons in the following locations:

- On 09/29/14 at 11:39AM in a Janitor's Closet on the 1st Floor of the "1977" Building (near the Entrance to the CCU {Critical Care Unit}) a sprinkler was missing its escutcheon.

- On 09/30/14 at 2:30PM two (2) sprinklers in a Basement Medical Records Room in the "1977" Building were noted to be missing escutcheons.

- On 10/01/14 at 8:52AM a sprinkler in a Basement Mechanical Equipment Room (across from the M.I.S. Storage Room) in the "1955" Building was noted to be missing.

- On 10/01/14 at 11:07AM a sprinkler was noted to be missing an escutcheon cover plate in the Basement level landing of the staircase to the Basement in the A-Wing of the "2001" Building.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken immediately.

c) During the survey sprinkler water discharge pattern development was found to be either obstructed, or areas were found to have inadequate sprinkler protection in the following locations:

- On 09/29/14 at 11:41AM only one (1) sprinkler was found to be installed in an "L" shaped room in the Splint Storage Room on the 1st Floor of the "1977" Building. The way that the walls of this room are arranged, and where the single sprinkler is located, the sprinkler would be unable to provide complete protection of this room.

- On 09/30/14 at 11:39AM the discharge pattern of a pendent sprinkler located in "Frank's Locked Storage Room" in the Basement of the "1955" Building was noted to be partially obstructed by a light fixture.

- On 09/30/14 at 12:18PM the discharge pattern of two (2) pendent sprinklers located in the Elevator Machine Room in the Basement of the "1955" Building were noted to be partially obstructed by a light fixture.

- On 09/30/14 at 1:40PM only one (1) sidewall-type sprinkler was provided in the bottom of the Elevator shaft that serves the Hydraulic Elevators in the A-Wing of the "2001" Building and it was unclear at the time of the inspection that this single sprinkler could provide adequate protection of the Elevator shaft.

- On 10/01/14 at 9:06AM a portion of a Basement Mechanical Equipment Room (i.e., Sprinkler Zone Valve 3 Room) in the "1955" Building lacked complete sprinkler protection.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken immediately.

d) During the survey, foreign materials (e.g., paint, joint compound, or firestopping caulk) were noted on sprinklers or sprinkler escutcheon cover plates in the following locations:

- On 09/29/14 at 11:56AM in Sleeping Suite #2 on the 1st Floor of the "1955" Building, paint was noted on two (2) of the sprinklers in this room.

- On 09/30/14 at 1:52PM a sprinkler in the Pharmaceutical Waste Storage Room in the Basement of the "1955" Building was noted to have a foreign material (e.g., joint compound) on it.

- On 09/30/14 at 2:38PM seven (7) sprinklers in a Basement corridor (the "Respiratory" corridor) in the "1955" Building were noted to have a foreign material (e.g., paint) on them.

- On 10/01/14 at 8:47AM two (2) sprinklers in a Basement Pneumatic Tube Room in the "1955" Building were noted to have a foreign material (e.g., one {1} with firestopping caulk and the other with joint compound) on them.

- On 10/01/14 at 8:48AM a sprinkler in the bottom landing of an Exit stair from the Basement of the "1955" Building (located by the Pneumatic Tube Room) was noted to have a foreign material (e.g., joint compound) on it.

- On 10/01/14 at 9:06AM a sprinkler in the Basement Laboratory Staff Break Room in the "1955" Building had a foreign material (e.g., joint compound) on it.

- On the afternoon of 10/02/14 the escutcheon cover plates of four (4) out of four (4) sprinklers in Operating Room #1 and four (4) out of four (4) sprinklers in Operating Room #2 on the 2nd Floor of the A-Wing in the "2001" Building were noted to have a foreign material (e.g., paint) on them.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken immediately.

e) On the afternoon of 10/02/14 review of the 08/05/14 "Automatic Sprinkler Systems Annual Inspection, Tests, and Maintenance" Report prepared by the facility's outside Vendor responsible for inspecting, testing, and maintaining the sprinkler system, stated that the Vendor "physically inspected the fire sprinkler system" but did not note any deficiencies with the sprinkler system during his inspection. NFPA 25 requires that "Sprinklers be inspected from the floor level annually. Sprinkles shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-1, Table 2-1

10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based on observations and staff interviews, the facility failed to ensure that automatic sprinkler systems were maintained in accordance with the requirements found in NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

The findings include, but are not limited to, the following examples:

a) On the morning and afternoon of 09/30/14 sprinkler system pressure gauges in several locations (e.g., the "1955" Building Basement Boiler / Sprinkler Zone #2 Room, the "1955" Building Basement Respiratory Therapy Offices / Sprinkler Zone #5 Room and the "1977" Building Basement Medical Records Area Mechanical Room / Sprinkler Zones #6A and #6B), were labeled that they were manufactured in 1996. As per interview with the facility's Director of Engineering on 09/30/14 at 11:01AM, he was not sure when the sprinkler Vendor who maintains the sprinkler system replaced or tested sprinkler system pressure gauges.

On the morning of 10/02/2014, record reviews revealed that the facility did not have any records pressure gauge calibration or replacement. Pressure gauges are required to replaced or recalibrated once every five (5) years). As per interviews with the facility's Director of Engineering at 1:15PM, he is trying to obtain these documents from the Vendor who maintains the sprinkler system.

b) On 10/01/14 at 8:55AM sprinkler protection was noted to be provided in the interstitial space above the suspended ceiling in the Basement of the "1955" Building (in the corridor by the Laboratory Wing). As per concurrent interview with the facility's Director of Engineering, these sprinklers may date back to the original construction of this Building (e.g., 1955). He said he will check with the facility's sprinkler Vendor to determine the exact act of these sprinklers and if they need to be replaced or retested due to their age.

c) On the morning of 10/02/14 a sprinkler system Post Indicator Control Valve located on the South side of the facility (outside of the Emergency Room Entrance, near Hempstead Turnpike) and a sprinkler system Post Indicator Control Valve located on the West side of the facility (outside of the Coffee Shop) was noted to lack signage which would indicate what sprinkler zones they controlled. All control, drain and test connection valves are required to be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means. As per interview with the facility's Director of Engineering on 10/02/14 at 10:25AM, he will have required identification signage installed as soon as possible.

d) On 10/01/14 at 11:24AM it was noted the Spare Sprinkler Storage Cabinet in the A-Wing Basement Boiler / Mechanical Equipment / Fire Pump Room in the "2001" Building lacked one (1) spare upright, one (1) spare sidewall and two (2) spare dry-head sprinklers. NFPA 25-1998 Chapter 2-4.1.4 requires that "A supply of at least six (6) spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two (2) sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100°F (38°C)." As per concurrent interview with the facility's Director of Engineering, he will ensure that the Vendor responsible for maintaining the sprinkler system provides an adequate supply of spare sprinklers.

e) On the afternoon of 10/02/14 record review revealed that the facility did not have any records for the following items that are supposed to be conducted every five (5) years on the sprinkler system: inspection of alarm and check valve and obstruction investigation. As per interviews with the facility's Director of Engineering at 1:15PM, he is trying to obtain these documents from the Vendor who maintains the sprinkler system.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 19.7.6, 9.7.5, 4.6.12, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-1, Table 2-1, 9-1, Table 9-1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interview, the facility did not ensure that vertical ventilation ducts in the Building were protected in accordance with NFPA 90A.

Findings:

On 09/29/14 at 10:05AM a ceiling exhaust ventilation duct opening in the T-Wing Nurses' Station Crash Cart / Oxygen Tank Storage Alcove on the 1st Floor of the "1955" Building was not properly enclosed by ductwork. There is an approximately five (5) inch gap between the duct opening in the suspended ceiling and the exhaust ventilation duct that it is supposed to be attached to.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.2.1, 9-2, NFPA 90A-1999, Standard for the Installation of and ventilating Systems: 2-3.5.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interview, the facility failed to ensure that required placards identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system were conspicuously placed near each portable fire extinguisher in Cooking Areas.

Findings:

On 09/30/14 at 9:45AM the facility was found to lack the required placard (sign) identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system near the portable "K" type fire extinguishers in the 1st Floor Coffee Shop Food Preparation / Cooking Area on the 1st Floor of the "1955" Building. The required placard shall state "WARNING: In case of appliance fire use this extinguisher after fixed suppression system has been used". As per concurrent interview with the facility's Director of Engineering, he will have the required placard installed as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96-1998 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 7-2.1.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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Based on observations and staff interviews, the facility failed to ensure that means of egress were continuously maintained free of all obstructions or impediments to full and instant use in case of fire or other emergency.

Reference is made to the following:

On 10/01/14 at 11:32AM a filing cabinet filled with fan belts was found to be improperly stored at the Rooftop Level landing of the North Exit Staircase in the A-Wing of the "2001" Building. As per concurrent interview with the facility's Director of Engineering, this filing cabinet should not be stored inside an Exit enclosure and he will instruct one of his staff to remove the filing cabinet immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.2.1, 7.1.10.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interviews, the facility failed to ensure that piped oxygen was not piped to, or used for, any purpose except for use in patient care applications.

Findings:

On 09/30/14 at 9:50AM an oxygen supply outlet located in a former Labor/Delivery Room that had been converted into an Emergency Preparedness Supply Storage Room was noted to be leaking. As per concurrent interview with the facility's Director of Engineering, immediate corrective action will be taken.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 12-3.4.1, Ch. 4
10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based on observations and staff interviews, the facility failed to ensure that where extinguishment or control of fire is effectively accomplished by a type of automatic extinguishing system other than an automatic sprinkler system, such as Halon 1301, that such systems shall be installed, inspected and maintained in accordance with appropriate NFPA standards.

Findings:

a) On 09/29/14 at 10:50AM the CAT Scan Room on the 1st Floor of the "1955" Building was found to be protected by a Halon System. The door from the CAT Scan Room to the adjacent CAT Scan Control Room lacked a self-closing or automatic closing device. In addition, the self-closing device on the door from the CAT Scan Room into the Radiology Suite was found to be broken and did not function properly. In order to prevent loss of agent through openings to adjacent hazards or work areas, openings, such as these doors, shall be permanently sealed or equipped with automatic closures. As per concurrent interview with the facility's Director of Engineering, he takes corrective action immediately.

b) On 09/30/14 at 2:58PM the Main Computer Server Room in the Basement of the "1955" Building was found to be protected by a Halon System. A Closet that contains the Halon System tank opens directly into the Server Room and lacks a self-closing device. In addition, the enclosure walls that separate this Closet from the adjacent Server Room had an unsealed cable penetration and the Closet lacked sprinkler protection and did not appear to be protected by the Halon System (e.g., no nozzle was provided in this Closet). As per concurrent interview with the facility's Director of Engineering, he will take corrective action immediately.

42 CFR 482.41 (b), NFPA101-2000 Life Safety Code: 9.7.3, NFPA 12A, Standard on Halon 1301 Fire Extinguishing Systems: 3-3.1.2, 4-1.1

10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based on observations and staff interview, the facility did not ensure that Exiting from all assembly use areas was in compliance with all of the requirements found in NFPA 101.

Findings:

On 09/29/14 at 3:07PM the Staff Dining Room in the Basement of the "1955" has an occupant load greater than fifty (50) people (e.g., ninety-six {96} people). The doors to this room were noted to open into the room and did not swing in the direction of exit travel. Doors in rooms or areas that have more than an occupant load of fifty (50) are required to swing in the direction of exit travel. As per concurrent interview with the facility's Director of Engineering, he will take corrective action as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 13.2.1, 7.2.1.4.2

10NYCRR, 405.24 (b), 711.2 (a) (1)


3. Based on observations and staff interview, the facility failed to ensure that the standpipe system was properly maintained.

Findings:

On the morning of 10/01/14 it was noted that standpipe system hose connection caps were missing in several locations (e.g., at rooftop standpipe in the South Exit Stair) in the A-Wing of the "2001" Building. As per interview with the facility's Director of Engineering on 10/01/14 at 11:39AM, the facility has had chronic problems with the hose connection caps being stolen. It was recommend by the Surveyors that the facility replace the missing brass caps with less valuable plastic caps.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 9.7.5, NFPA 25-1998, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 3-1, 3-2.3, Table 3-2.3

10NYCRR, 405.24 (b), 711.2 (a) (1)


4. Based on observations, record review and staff interviews, the facility failed to ensure that required two (2) hour fire resistance rated separation was maintained between the Existing Health Care Occupancy on the 1st Floor of the "1955" Building and the Existing Business Occupancy and Existing Storage Occupancy located in the Basement of the "1955" Building.

Findings:

Multiple observations made during the survey on 09/29/14, 09/20/14 and 10/01/14 revealed that the single story plus Basement "1955" Building was of Type V (000) Unprotected Combustible construction due to the use of unprotected wood structural members throughout the building. This is a permitted construction type for a single story Existing Health Care Occupancy provided that the building is provided that the building is provide throughout by a supervised, automatic sprinkler system. During the survey it was noted that sprinkler were missing from a couple of required locations in the "1955" Building and that the sprinkler system also lacked required supervisory devices on all sprinkler control valves (see K56 and K62 for additional information). NFPA 101-2000 Section 19.1.2.3 requires that health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two (2) hours as provided for additions in Section 19.1.1.4.

Record review (Life Safety Floors Plans for the facility dated 01/22/14) and staff interviews on the morning of 09/29/14 revealed that different sections / use areas of the Basement of the "1955" Building were classified as either Existing Business Occupancy or Existing Storage Occupancy.

Observations revealed that there was no two (2) hour fire resistance rated horizontal barrier to separate the Basement of the "1955" Building from the 1st Floor. Examples include:

- On 09/30/14 at 10:50AM an approximately eight (8) inch by four (4) foot hole was noted in what had been a rated ceiling assembly in a basement Linen Department Office/Storage Area.

- On 09/30/14 at 11:08AM an approximately ten (10) foot by four (4) foot hole, an approximately twelve (12) inch by twelve (12) inch hole, and an approximately eighteen (18) inch by six (6) inch hole were noted in what had been a rated ceiling assembly in a Basement Environmental Services Office.

- On 09/30/14 at 11:15AM the Basement Exit access corridor located outside of the Environmental Services Office was noted to lack any fire resistance rated ceiling assembly (it appears that if there ever was a fire resistance rated ceiling assembly in this corridor that it had been removed at some point in the past).

- On 09/30/14 at 12:03PM an approximately eight (8) inch by six (6) inch hole was noted in what had been a rated ceiling assembly in a Basement Kitchen Dry Goods Storage Area.

- 09/30/14 at 12:12PM an approximately three (3) inch by five (5) inch hole was noted in what had been a rated ceiling assembly in a Basement Plumbing Supply Storage Room.

- On 09/30/14 at 12:20PM the Basement Exit access corridor located outside of the Elevator Lobby and the Pharmacy Area was noted to lack any fire resistance rated ceiling assembly (it appears that if there ever was a fire resistance rated ceiling assembly in this corridor that it had been removed at some point in the past).

- On 10/01/14 at 8:35AM the Basement Exit access corridor located outside of the Laboratory Area was noted to lack any fire resistance rated ceiling assembly (it appears that if there ever was a fire resistance rated ceiling assembly in this corridor that it had been removed at some point in the past).

- On 09/30/14 at 9:32AM several different sized holes were noted in what had been a rated ceiling assembly in a Basement Lab Formaldehyde Storage Room.

As per interviews with the facility's Director of Engineering and the Corporate Life Safety Director on 10/02/14 at 10:10AM, they will probably request a Waiver for the lack of a two (2) hour fire resistance rated ceiling assembly in the Basement of the "1955" Building based on the building having complete automatic sprinkler protection.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.1.6.2, Table 19.1.6.2, 19.1.2.3, 19.1.1.4, 8.2.3

10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based on observations and record (i.e., Panel Board Schedule / Circuit Directory) reviews, and staff interviews during the survey, the facility was not provided with a Type 1 Essential Electrical System that was divided into separate Critical Branch, Life Safety Branch and Equipment Systems in accordance with NFPA 99. In addition, the facility failed to ensure that normal service wiring was separated from emergency service wiring. These deficiencies were noted in existing areas of the facility.

The findings include, but are not limited, to the following:

a) On 09/29/14 at 11:15AM review of the Emergency Power Panel Directory for Panel "EM0006 (CR)" on the 1st Floor of the "1955" Building revealed that this Panel served both Emergency System-Critical Branch Loads (e.g., room receptacles) and Equipment System Loads (e.g., rooftop air conditioning unit). As per concurrent interview with the facility's Director of Engineering, the facility has an ongoing project to upgrade the facility's Emergency Power System so that it meets Type 1 Essential Electrical System requirements. He also said that he has an approved Waiver for the lack of a Type 1 Essential Electrical System from the New York State Department of Health and an approved Time-Limited Equivalency for the lack of a Type 1 Essential Electrical System from the Joint Commission.

b) On 09/29/14 at 12:32PM review of the Emergency Power Panel Directory for Panel "EM0028" on the 1st Floor of the "1955" Building revealed that this panel served both Emergency System-Life Safety Branch Loads (e.g., fire alarm strobes) and Emergency System-Critical Branch Loads (e.g., receptacles, exhaust fan).

c) On 09/29/14 at 1:55PM review of the Emergency Power Panel Directory for Panel "EM0012" on the 1st Floor of the "1955" Building revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit sign) and Emergency System-Critical Branch Loads (e.g., receptacles, x-ray).

d) On 09/29/14 at 2:02PM review of the Emergency Power Panel Directory for Panel "EM0020" on the 1st Floor of the "1955" Building revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Alarm power booster, lights) and Emergency System-Critical Branch Loads (e.g., receptacles).

e) On 09/29/14 at 2:38PM observations in the 1st Floor MRI Unit Electrical Room revealed that wiring from Emergency System-Critical Branch Panel "1E-CR" was improperly run into the same metal raceway containing wiring from Emergency System-Life Safety Branch Panel "1E-LS" without any physical separation between the wiring from the two (2) different branches. Wiring from the Emergency System-Critical Branch is required to be kept separate from the Emergency System-Life Safety Branch. In addition, in the same room, wiring from Emergency System Panel "1E-EQ" and wiring from Normal Power Panel Board "1N" are also run through a common raceway.

f) On 09/30/14 at 8:20AM review of the Emergency Power Panel Directory for Panel "EM0040" on the 1st Floor of the "1955" Building revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit signs and lights) and Emergency System-Critical Branch Loads (e.g., receptacles, Nurse Call System, Argon Laser).

g) On 09/30/14 at 9:35AM wiring for Emergency System-Critical Branch duplex receptacles was not separated from Normal Power System duplex receptacles in quad receptacles boxes in the 1st Floor M-Wing Orthopedic Equipment Storage Room in the "1955" Building. There is no physical separation (e.g., a barrier) to separate the Emergency System wiring from the Normal power wiring. As per concurrent interview with the facility's Director, separation of Normal from Emergency System wiring is part of the facility's ongoing Electrical System upgrade / modernization project.

h) On the morning of 09/30/14 review of the Emergency Power Panel Directory for Panel "EM0014" on the 1st Floor of the "1955" Building revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit stairway lighting, Exit access corridor lighting, the Intercom System) and Emergency System-Critical Branch Loads (e.g., receptacles, task lighting, Isolation Room fans).

i) On the morning of 09/30/14 review of the Emergency Power Panel Directory for Panel "EM0082" in the Basement Kitchen of the "1955" Building revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit signs, Alarm relays) and Equipment System Loads (e.g., coffee machine).

j) On 09/30/14 at 2:00PM in the Basement Generator / Electrical Room (in the Medical Records Wing of the "1977" Building) wiring from Emergency System-Life Safety Branch Panel "EELS-0104", Emergency System-Critical Branch Panel "GECR-0111" and Equipment System Panel "EEEQ-0112" were noted to run from separate conducts into a common electrical junction box. In addition, an electrical conduit is this room was connected to both duplex receptacles (an Emergency System-Critical Branch Load) and an Exit sign and emergency lighting fixture (Emergency System-Life Safety Branch Loads).

k) On 09/30/14 at 2:28PM in the Basement CCU (Critical Care Unit) Mechanical Room (in the Medical Records Wing of the "1977" Building), wiring that served the Medical Air System Local Carbon Monoxide and Dew Point Alarms was found to be powered by an electrical conduit that was labeled "GECR Circuits 21, 23". Panel "GECR" is an Emergency System-Critical Branch Panel but NFPA 99 requires that Local, Area and Master Gas Alarm Systems be "powered from the Life Safety Branch of the Emergency System". As per concurrent interview with the facility's Director of Engineering, he will notify his consultant Electrical Engineer about this issue.

l) On 10/01/14 at 9:10AM review of the Emergency Power Panel Directory for Panel "EM0102" in the Basement Laboratory Stock Room in the "1955" Building revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit signs, lights) and Emergency System-Critical Branch Loads (e.g., Laboratory refrigerator and receptacles, Wire Mold Lab.).

m) On 10/01/14 at 10:58AM review of the Emergency Power Panel Directory for Panel "LC-CR-MS-Sect 2" in a 1st Floor Electrical Room (near Janitor's Closet #S135) in the S-Wing of the "2001" Building revealed that this Panel served Emergency System-Life Safety Branch Loads (e.g., fire smoke dampers), Emergency System-Critical Branch Loads (e.g., Nurse Call System, receptacles, pneumatic tube, corridor receptacles) and Equipment System Loads (e.g., heat trace).

n) On 10/01/14 at 12:31PM observations in the A-Wing 1st Floor Electrical Closet A131A in the "2001" Building revealed that wiring from Emergency System-Critical Branch Panel "LP-CR-1A1 Sect.2" was improperly run into the same metal raceway as well as a conduit containing wiring from Normal Power Panel "LP1A Sect. 1" without any physical separation between the wiring from the two (2) different branches.

o) On 10/01/14 at 1:54PM review of the Emergency Power Panel Directory for Panel "EDP-OR" in a 2nd Floor Electrical Room (by the Elevator Lobby) in the A-Wing of the "2001" Building revealed that this Panel served Emergency System-Life Safety Branch Loads (e.g., fire smoke dampers) and Emergency System-Critical Branch Loads (e.g., Operating Room receptacles). In addition, review of the Emergency Power Panel Directory for Panel "LP-CR-2B" in the above-mentioned Electrical Closet revealed that this Panel served Emergency System-Critical Branch Loads (e.g., Operating Room lights, pneumatic tube, a medication refrigerator and Holding Area receptacles) and an Equipment System Load (e.g., hot water heater).

p) On the morning of 10/02/14 review of Waiver / Equivalency Documents that the facility had been previously issued revealed that:

- The New York State Department of Health had, on 01/15/02, granted a Waiver to the facility for the lack of a Type 1 Essential Electrical System in the "2001" Building. Approval of this Waiver was contingent on the facility developing a documented Preventative Maintenance Program that meets the requirements of NFPA 110, Standard for Emergency and Standby Power Systems. This deficiency was noted during the 11/07/01 Pre-Occupancy Inspection of the "2001" addition to the facility. No expiration date was provided on this Waiver.

- The New York State Department of Health had, on 02/27/08, granted a Waiver to the facility for the lack of a Type 1 Essential Electrical System in the "1955" Building. Approval of this Waiver was contingent on the facility developing a Master Plan to upgrade the Emergency Power System to comply with the required regulations. This deficiency was noted during the 01/07/08 Pre-Occupancy Inspection of the Hyperbaric / Wound Care Unit Construction Project in the "1955" Building. No expiration date was provided on this Waiver.

- The Joint Commission had, on 09/05/08, issued an Equivalency for the lack of a Type 1 Essential Electrical System. Approval of this Equivalency was contingent on the facility providing annual updates on the progress of their Master Plan to upgrade / modernize the facility's Emergency Power System. This Equivalency has an expiration date of 10/01/18. The facility provided records of the annual updates that they submitted to the Joint Commission in 2009, 2010, 2011, 2012 and 2013.

On 10/02/14 at 10:00AM the facility's Director of Engineering and their Corporate Life Safety Director were informed that while they may have been issued Waivers from the Department of Health, and a Time-Limited Equivalency from the Joint Commission, they would need to submit a Waiver Request to the Centers of Medicare and Medicaid Services (CMS) for this deficiency.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9

10NYCRR, 405.24 (b), 711.2 (a) (1), 711.2 (a) (20)
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1. Based on observations and staff interview, the facility failed to ensure that electrical wiring was installed in a neat and workman like manner or maintained in good repair and that unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings were effectively closed to afford protection substantially equivalent to the wall of the equipment were provided in accordance with the requirements of the NFPA 70, National Electrical Code.

Findings:

a) On 09/29/14 at 9:50AM the housing of a Ground Fault Circuit Interrupter (GFCI) duplex receptacle in the Toilet Room of the T-Wing Staff Lounge on the 1st Floor of the "1955" Building was noted to be cracked.

b) On the morning 09/29/14 grounding pins from electrical plugs were found to have broken off inside of a corridor receptacle outside of Room T1 and in Storage Room T2 on the 1st Floor of the "1955" Building.

c) On 09/29/14 at 11:20AM the housing of a duplex receptacle in a wall of the Step-Down Unit (near Cubicle #1 and the Exit stair) on the 1st Floor of the "1977" Building was noted to be cracked.

d) On 09/30/14 at 9:45AM on the 1st Floor of the "1955" Building, a duplex GFCI receptacle located next to the grill in the Coffee Shop Food Preparation / Cooking Area was noted to have a very heavy build-up of grease on its exposed surfaces.

e) On 09/30/14 at 11:25AM in the Basement Dietary Compressor Machine Room in the "1955" Building, electrical wiring (a "BX" type cable) was found to have been improperly run up through a vertical ventilation system duct within this room. In addition, an open (i.e., uncovered) electrical wiring raceway and an open (i.e., uncovered) electrical junction box were also noted in this room.

f) On 09/29/14 at 2:13PM in the Basement of the "1977" Building, a duplex receptacle in a Medical Records Department Office was noted to be missing a cover plate.

g) On 10/01/14 at 12:05PM on the 1st Floor of the A-Wing in the "2001" Building, the plastic cover plate of a duplex receptacle in Emergency Department "Cardiac Room 1" was noted to be damaged (bent out of shape).

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken immediately. Many of the damaged receptacles were noted to have been replaced prior to the end of the survey.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12

10NYCRR, 405.24 (a) (1), 405.24 (e) (1), 405.24 (b), 711.2 (a) (1)


2. Based on observations and staff interview during the survey, the facility failed to ensure that all Panel Board circuits and circuit modifications were legibly identified as to purpose or use on a Circuit Directory located on the face or inside of the Panel doors in accordance with the requirements of the NFPA 70, National Electrical Code.

Findings:

a) On 09/29/14 at 11:27AM Normal Power Panel "PP-EM2A" by the Nurses' Station in the Step Down Unit on the 1st Floor of the "1977" Building was noted to lack a Circuit Directory.

b) On 09/29/14 at 12:30PM Normal Power Panel "LP-1P" on the 1st Floor of the "1955" Building was noted to have several circuits (e.g., Circuits #3, #4, #6, #8 and #10) on the Circuit Directory in which their function was only identified as "In Use". The specific purpose that these circuits serve are required to be identified.

c) On 10/01/14 at 9:10AM in the Basement of the "1955" Building, Emergency Power Panel "EM0102" was noted to have several circuits (e.g., Circuits #16, #18, #20, #22 and #24) on the Circuit Directory in which their function was only identified as "In Use". The specific purpose that these circuits serve are required to be identified.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13

10NYCRR, 405.24 (b), 711.2 (a) (1)


3. Based on observations and staff interview, the facility failed to ensure that listed tamper resistant electrical receptacles were provided in the Pediatric Treatment Area.

Findings:

On 09/29/14 at 8:50AM on the 1st Floor of the "1955" Building, three (3) duplex electrical receptacles in the Speech and Swallowing Unit Pediatric Treatment Area were noted to not be listed tamper-resistant receptacles. As per concurrent interview with the facility's Director of Engineering, he will have listed tamper-resistant receptacles installed as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 517-18 (c)

10NYCRR, 405.24 (b), 711.2 (a) (1)


4. Based on observations and staff interviews, the facility failed to ensure that flexible cords and cables were not used as a substitute for the fixed wiring of a structure.

Findings:

a) On 09/30/14 at 9:10AM in the B-Wing Nurses' Station on the 1st Floor of the "1955" Building, two (2) relocatable power taps (e.g., "surge protectors") were found to be improperly attached in sequence to each other (i.e., "daisy chained"). The facility's Director of Engineering said that he will try to have additional duplex electrical receptacles installed in this area so that electrically powered equipment can be properly connected directly to fixed wiring.

b) On 09/30/14 at 9:12AM in the B-Wing Case Manager's Office on the 1st Floor of the "1955" Building, two (2) relocatable power taps (e.g., "surge protectors") were found to be improperly attached in sequence to each other (i.e., "daisy chained"). The facility's Director of Engineering said that he will try to have additional duplex electrical receptacles installed in this area so that electrically powered equipment can be properly connected directly to fixed wiring.

c) On 09/30/14 at 2:16PM in the Basement of the "1977" Building, B-Wing a relocatable power tap (e.g., "surge protector") was found to be improperly attached in sequence to an extension cord (i.e., "daisy chained"). The facility's Director of Engineering said that he will try to have additional duplex electrical receptacles installed in this area so that electrically powered equipment can be properly connected directly to fixed wiring.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3, 400-8

10NYCRR, 405.24 (b), 711.2 (a) (1)


5. Based on observations and staff interview during the survey, the facility failed to ensure that a Ground Fault Circuit Interrupter (GFCI) protected receptacle was installed in close proximity (i.e., within six {6} feet) of sinks or similar locations where the electrical receptacle may be subject to wetting.

Findings:

On 10/01/14 at 2:30PM on the 2nd Floor of the A-Wing in the "2001" Building, a duplex receptacle that was not a Ground Fault Circuit Interrupter (GFCI) protected receptacle was found to have been installed only twenty (20) inches from an Emergency Eye Washing Station. As per concurrent interview with the facility's Director of Engineering, the above-mentioned receptacle will be replaced by a Ground Fault Circuit Interrupter (GFCI) protected receptacle as soon as possible.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 210-8 (b)

10NYCRR, 405.24 (a) (1), 405.24 (b), 711.2 (a) (1)


6. Based on observations and staff interview during the survey, the facility failed to ensure that all Critical Care Areas were provided with receptacles from both the Emergency System-Critical Branch and the Normal Power System.

Findings:

On 10/01/14 at 2:38PM on the 2nd Floor of the A-Wing in the "2001" Building, all of the electrical receptacles in A223-Operating Room #1 were found to be served by the Emergency System-Critical Branch. As per concurrent interview with the facility's Director of Engineering, he will have a Normal Power System receptacle installed in this location as soon as possible.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 517-19 (a)

10NYCRR, 405.24 (a) (1), 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interview, the facility failed to ensure that alcohol based hand rub dispensers were not installed directly over an ignition source.

Findings:

On 09/30/14 at 2:17PM an alcohol based hand rub dispenser was noted to have been installed directly above an ignition source (e.g., a light switch) in the Medical Records Customer Service Area in the Basement of the "1977" Building. As per concurrent interview with the facility's Director of Engineering, he will have this dispenser relocated immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.2.7

10NYCRR, 405.24 (b), 711.2 (a) (1)

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Based on observations and staff interviews, the facility failed to ensure that if a building containing a healthcare occupancy has a common wall with a non-conforming building that the common wall has at least a two (2) hour fire resistance rating. Specific reference is made to the two (2) hour fire barrier walls that separate the non-conforming "1955" Building from the "1977" and "2001" Buildings.

Findings:

On 09/29/14 at 11:05AM an unsealed cable penetration was noted above a set of cross-corridor fire doors in the two (2) hour combination fire / smoke barrier wall that separates the 1st Floor of the "1955" Building from the 1st Floor of the "1977" Building. As per concurrent interview with the facility's Director of Engineering, he will have this penetration sealed immediately.

On 09/30/14 at 10:10AM, the top-of-wall assembly of the two (2) hour fire barrier that separates the 1st Floor of the "1955" Building from the "2001" Building (vicinity of the "1955" Building B-Wing Decontamination Equipment Storage Room and Linen Storage Room) was not sealed with firestopping. As per concurrent interview with the facility's Director of Engineering, he will have this deficiency corrected immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.1.1.4.1, 8.2.3

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interviews, the facility failed to ensure that corridors were separated from all other areas, including Patient Areas, by partitions complying with Sections 19.3.6.2 through 19.3.6.5. Specifically, Section 19.3.6.2.2 requires that corridor walls form a barrier to prevent the transfer of smoke.

Findings:

On 09/29/14 at 1:30PM an approximately twelve (12) inch by twelve (12) inch non-ducted air transfer grill (opening) was noted between an Exit access corridor wall and the 1st Floor Physical Therapy Treatment Area in the "1955" Building. As per concurrent interview with the facility's Director of Engineering, he will have this unprotected air transfer opening sealed immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.6.2.2

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interview, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 19.3.6.3.2 requires that corridor doors in Existing Health Care Occupancies be provided with a means suitable for keeping the door closed that is acceptable to the Authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings:

On 10/01/14 at 10:57AM the inactive leaf to a set of double doors to Communication Room S137 in the S-Wing of the "2001" Building was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire. As per concurrent interview with the facility's Director of Engineering, he has already initiated a facility-wide project to replace all of the manual flush bolts on the inactive leaves of doors with approved automatic flush bolts. He said that the project should be completed in the very near future.

On 10/01/14 at 11:42AM the inactive leaf to a set of double doors to Electrical Closet A147 in the 1st Floor of the A-Wing in the "2001" Building was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire.

On 10/01/14 at 12:34PM the inactive leaf to a set of double doors to Electrical Closet A131A in the 1st Floor of the A-Wing in the "2001" Building was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.6.3.2

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interview, the facility failed to ensure that all vertical penetrations of fire barriers were enclosed with construction having at least a one (1) hour fire resistance rating.

Findings:

On 09/29/14 at 11:08AM an unsealed vertical plumbing penetration was noted inside the floor of the Exit stair into the CCU Wing in the "1977" Building (vicinity of the landing that serves the door to the outside). As per concurrent interview with the facility's Director of Engineering, this penetration will be sealed immediately.

On 09/29/14 at 11:18AM an unsealed vertical cable penetration was noted in the floor of the 1st Floor Respiratory Department Office (near the entrance to the Step-Down Unit) in the "1977" Building. As per concurrent interview with the facility's Director of Engineering, this penetration will be sealed immediately.

On 09/30/14 at 9:46AM an unsealed vertical cable penetration was noted in the floor of the 1st Floor of the old Linen Chute Room "C" Unit in the "1955" Building. As per concurrent interview with the facility's Director of Engineering, this penetration will be sealed immediately

On 09/30/14 at 10:43AM six (6) unsealed plumbing penetrations were noted in the ceiling / floor assembly in the Wing 7 Large Storage Room in the Basement of the "1955" Building. As per concurrent interviews with the facility's Director of Engineering, these penetrations will be sealed immediately.

On 09/30/14 at 11:01AM an unsealed vertical plumbing penetration was noted in the ceiling / floor assembly in the Housekeeping Equipment Room (where the Sprinkler Zone #1 valve is located) in the "1955" Building. As per concurrent interviews with the facility's Director of Engineering, these penetrations will be sealed immediately.

On 10/01/14 at 8:41AM an unsealed vertical plumbing penetration was noted in the ceiling / floor assembly in the Basement Pneumatic Tube Room in the "1955" Building. As per concurrent interview with the facility's Director of Engineering, this penetration will be sealed immediately.

On 10/01/14 at 9:25AM two (2) unsealed cable penetrations and an unsealed plumbing penetration were noted in the Basement-Level enclosure walls of the accessory staircase that serves the Physician On-Call Room in the Basement of the "1955" Building. As per concurrent interview with the facility's Director of Engineering, this penetration will be sealed immediately

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.1.1, 8.2.5

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interview, the facility failed to ensure that doors in smoke barriers were self-closing and kept in the closed position, unless held open by a release device complying with Section 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:

a) The required manual fire alarm system, and

b) Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system, and

c) The automatic sprinkler system.

Findings:

On 09/30/14 at 8:26AM a smoke barrier door (i.e., the door to the Chaplin's Office in a two (2) hour rated combination smoke / fire barrier on the 1st Floor of the "1955" Building was found to be improperly held open by a magnetic hold-open device that was incapable of automatically releasing this door.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.7.7.6, 19.2.2.6, 8.3.4

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interviews, the facility failed to ensure that existing smoke barrier walls were constructed to have at least a one-half (½) hour fire resistance rating.

Findings:

On 09/29/14 at 1:35PM an unsealed cable penetration was noted above a set of fire doors (doors are identified by signage as "G-Wing-4-032") in the two (2) hour rated combination fire / smoke barrier near the Sleep Laboratory Area on the 1st Floor of the "1955" Building. In addition, the damper actuator arm on a fire / smoke damper in a duct that penetrates the above-mentioned fire / smoke barrier wall was found to be in disrepair (broken) and the duct was found to have been sealed with a firestopping material (caulk) rather than by metal angles. Firestopping material may, when exposed to the heat of a fire, expand and could crush the duct and prevent the fire/smoke damper within the duct from operating properly.

On 09/29/14 at 2:17PM two (2) unsealed cable penetrations were noted in a two (2) hour combination fire / smoke barrier near the MRI Suite and Wound Care Unit on the 1st Floor of the "1955" Building.

On 09/30/14 at 8:30AM a wall-joint of an approximately six (6) inch long section of a soffit (above cross-corridor door openings) in the two (2) hour combination fire / smoke barrier near the Chaplin's Office and the Waiting Room on the 1st Floor of the "1955" Building was sealed with non-fire resistance rated materials (e.g., joint compound and sheetrock tape) rather than approved firestopping materials.

On the morning of 10/01/14 between 10:39AM and 10:50AM, the following were noted:

- An unsealed cable and beam penetration were noted in a one (1) hour fire resistance rated smoke barrier wall in the Staff Toilet Room located across from Janitor's Closet S135 on the 1st Floor of the S-Wing in the "2001" Building.

- Two (2) duct penetrations of a one (1) hour fire resistance rated smoke barrier wall (above the cross-corridor doors near the Staff Toilet Room and Janitor's Closet S135 on the 1st Floor of the S-Wing in the "2001" Building) that contained a fire / smoke damper were found to have been sealed with a firestopping material (caulk) rather than by metal angles.

- Three (3) duct penetrations of a one (1) hour fire resistance rated smoke barrier wall (above the cross-corridor doors near Patient Room S116 and Soiled Utility Room S133 on the 1st Floor of the S-Wing in the "2001" Building) that contained a fire / smoke damper were found to have been sealed with a firestopping material (caulk) rather than by metal angles.

On the afternoon of 10/01/14 between 12:20PM and 12:47PM the following was noted:

- A duct penetration of a one (1) hour fire resistance rated smoke barrier wall (in a corridor by the entrance to the ED X-Ray Room on the 1st Floor of the A-Wing of the "2001" Building) that contained a fire / smoke damper was found to have been sealed with a firestopping material (caulk) rather than by metal angles.

- A cable penetration in a one (1) hour fire resistance rated smoke barrier wall (in a corridor above the newly constructed storage closet by the entrance to the ED X-Ray Room on the 1st Floor of the A-Wing of the "2001" Building) was found to be sealed with a non-fire resistance rated material (e.g., joint compound).

- An unsealed cable penetration in a one (1) hour fire resistance rated smoke barrier wall was noted above Electrical Closet A131A on the 1st Floor of the A-Wing of the "2001" Building.

- Two (2) unsealed cable and one (1) unsealed plumbing penetrations in a one (1) hour fire resistance rated smoke barrier wall were noted in the vicinity of Pre-Surgical Testing Room II on the 1st Floor of the A-Wing of the "2001" Building.

- A partially sealed plumbing penetration was noted in a one (1) hour fire resistance rated smoke barrier wall above a set of cross corridor smoke barrier doors in the vicinity of the Ambulatory Surgery Unit Admitting Area on the 1st Floor of the A-Wing of the "2001" Building.

- An unsealed cable penetration and an unsealed plumbing penetration were noted in a one (1) hour fire resistance rated smoke barrier wall near a Toilet Room by the Ambulatory Surgery Unit Admitting Area on the 1st Floor of the A-Wing of the "2001" Building.

On the afternoon of 10/01/14 between 2:22PM and 3:00PM, the following was noted:

- A duct penetration of a one (1) hour fire resistance rated smoke barrier wall (above the cross-corridor doors near Soiled Utility Room A201 on the 2nd Floor of the A-Wing in the "2001" Building) that contained a fire / smoke damper was found to have been sealed with a firestopping material (caulk) rather than by metal angles.

- Two (2) unsealed cable penetrations in a one (1) hour fire resistance rated smoke barrier wall were noted in the vicinity of Communications Closet A244B on the 2nd Floor of the A-Wing of the "2001" Building. In addition, a duct penetration of the one (1) hour fire resistance rated smoke barrier wall near Communications Closet A244B that contained a fire / smoke damper was found to have been sealed with a firestopping material (caulk) rather than by metal angles.

- Two (2) duct penetrations of a one (1) hour fire resistance rated smoke barrier wall (above the cross-corridor doors near the entrance to the A205 Surgical Holding Area on the 2nd Floor of the A-Wing in the "2001" Building) that contained a fire / smoke damper were found to have been sealed with a firestopping material (caulk) rather than by metal angles.

As per concurrent interviews with the facility's Director of Engineering, all of the penetrations will be sealed with approved firestopping systems as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interview, the facility failed to ensure that smoke barrier doors were self-closing.

Findings:

On 10/01/14 at 12:34PM the active and inactive leaves of a set of smoke barrier doors in Electrical Closet A131A on the 1st Floor of the A-Wing of the "2001" Building were found to lack required self-closing devices. As per concurrent interview with the facility's Director of Engineering, corrective action will be taken as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.7.6

10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based on observations and staff interview, the facility failed to ensure that all newly constructed hazardous areas were enclosed in at least one (1) hour fire resistance rated enclosure walls and that existing hazardous areas were enclosed with smoke resistant walls.

Findings:

a) On 09/29/14 at 2:41PM an old Operating Room that had been converted into a Storage Room on the 1st Floor of the "1955" Building was found to have an approximately twenty-two (22) inch by forty (40) inch non-fire resistance rated vision panel in one (1) of the walls of this room.

b) On 09/30/14 at 9:29AM an unsealed cable penetration was noted in an enclosure wall of a former Patient Room that had been converted into a Storage Room in the B-Wing of the "1955" Building.

c) On 09/30/14 at 9:54AM an old C-Section Room that had been converted into a Storage Room on the 1st Floor of the "1955" Building was found to have an approximately twenty-two (22) inch by forty (40) inch non-fire resistance rated vision panel in one (1) of the walls of this room.

d) On 09/30/14 at 10:54AM three (3) unsealed cable penetrations were noted in the enclosure walls of a former Staff Training Room in the Basement of the "1955" Building that had been converted into a Linen Storage Room.

e) On 09/30/14 at 12:03PM an unsealed plumbing penetration was noted in one (1) of the enclosure walls of the Kitchen Dry Goods Storage Room in the Basement of the "1955" Building.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 18.3.2.1, 19.3.2.1

10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based on observations and staff interview, the facility failed to ensure that all door openings from hazardous areas were protected by self-closing, positive latching doors.

Findings:

On 09/30/14 at 9:56AM the door to a C-Wing File Storage Room in the 1st Floor of the "1955" Building was found to lack a self-closing device.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.2.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations, record reviews and staff interviews, the facility failed to ensure that battery-powered emergency lighting fixtures were maintained in operational condition.

Findings:

On 10/01/14 at 11:26AM a battery-powered light fixture that provides emergency illumination in the Fire Pump Area of the combination Boiler / Mechanical Equipment / Fire Pump Room in the Basement of the A-Wing of the "2001" Building failed to work when tested. As per concurrent interview with the facility's Director of Engineering, he will have the battery replaced in this emergency lighting fixture immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.2.9.2, 7.9

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on staff interview, the facility failed to ensure that all staff were aware of the locations of smoke barrier walls used to separate floors into separate smoke compartments for use during the horizontal evacuation during a fire incident.

Findings:

On 10/01/14 at 2:18PM, interview with the Nurse Manager of the Surgical Unit on the 2nd Floor of the A-Wing in the "2001" Building revealed that she did not know the correct location of the adjacent smoke compartment / area of refuge that would be used in the evacuation of the Operating Room (OR) Suite in the event of a fire. When asked where she would relocate patients to in the event of a fire in one of the Operating Rooms, she said that she would relocate them to the PACU (Post Anesthesia Care Unit) / Recovery Room. The PACU / Recovery Room is located within the same smoke compartment as the Operating Suite and would not be a safe area of refuge for patients and staff in the event of a fire.

Review of the facility's written Fire Plan for the Operating Room (Policy 32.B.0 Hospital Wide Fire Plan dated 10/2013) revealed that the instructions for where to relocate patients in the event of a fire in the Operating Room Suite were very vague and could be confusing to staff. As per interview with the facility's Safety Director on 10/01/14 at 2:22PM, he will update the OR Evacuation Plan so that it provides better clarification on the horizontal evacuation of the space.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.7.1.1, 19.7.2.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observation and staff interview, the facility failed to ensure that smoke detectors were properly maintained.

Findings:

On 09/30/14 at 1:40PM a smoke detector in the Elevator pit for the Elevator cabs in the A-Wing of the "2001" Building was found to have been improperly covered over with a plastic dust cover. As per concurrent interview with the facility's Director of Engineering, he will have this cover removed immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.4.1, 19.3.4.3.1, 9.6, 4.6.12, NFPA 72-1999, National Fire Alarm Code: 7-1.1.1, 7-1.1.2
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1. Based on observations and staff interviews, the facility failed to ensure that automatic sprinkler protection was provided in all required areas.

Findings:

a) On 09/29/14 at 1:25PM a Coat Closet on the 1st Floor Board Room in the "1955" Building was noted to lack required sprinkler protection.

b) On 09/30/14 at 1:25PM the bottom of the Elevator shaft that serves Hydraulic Elevators in the "1955" Building was noted to lack required sprinkler protection.

c) On 10/01/14 at 11:40AM the top of the Stairway shaft of the "Basement" Stair in the A-Wing of the "2001" Building was noted to lack required sprinkler protection.

d) On 10/01/14 at 12:14AM a newly constructed Storage Closet in an Exit access corridor by the Entrance to the Express Care Unit on the 1st Floor of the A-Wing in the "2001" Building was noted to lack required sprinkler protection.

e) On 10/01/14 at 2:10PM the bottom landing of the South Exit Stair (also known as the "OR Stairs") in the A-Wing of the "2001" Building was noted to lack required sprinkler protection.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 19.1.6.1, 9.7.1., NFPA 13-1999 Standard for the Installation of Sprinkler Systems: 5-1.1, 5-13.3.2

10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based on observations, record reviews and staff interviews, the facility failed to ensure that all valves that are capable of affecting the water supply to the automatic sprinkler system were provided with supervisory attachments arranged to sound a supervisory signal to indicate a condition that could impair the satisfactory operation of the sprinkler system.

Findings:

a) On the morning of 10/01/14 it was noted that the facility had at least four (4) Post Indicator Valves (PIVs) and a Reduced Pressure Zone (RPZ) valve that are capable of shutting off water to portions of the sprinkler system and that these valves all lacked supervisory attachments arranged to sound a supervisory signal to indicate a condition that could impair the satisfactory operation of the sprinkler system (e.g., tamper alarms). As per interview with the facility's Director of Engineering on 10/01/14, his staff conducts visual inspections of the sprinkler system PIVs at least three (3) times a day and conducts a visual inspection of the RPZ valve at least once a week to ensure that these valves are kept in the open position.

b) On the morning of 10/02/14 review of Waiver / Equivalency Documents that the facility had been previously issued revealed that the New York State Department of Health had, on 01/15/02, granted a Waiver to the facility for the lack of required supervisory devices on all sprinkler control valves. Approval of this Waiver was contingent on the facility conducting at least monthly visual inspections of the control valves. This deficiency was noted during the 11/07/01 pre-occupancy inspection of the "2001" addition to the facility. Record view also revealed that the Joint Commission had, on 09/05/08, issued an Equivalency for the lack of required supervisory devices on all sprinkler control valves. Approval of this Equivalency was contingent on the facility conducting at least three (3) visual inspections of the Post Indicator Valves. On 10/02/14 at 10:00AM the facility's Director of Engineering and their Corporate Life Safety Director were informed that while they may have been issued a Waiver from the Department of Health and an Equivalency from the Joint Commission, they would need to submit a Waiver request to the Centers for Medicare and Medicaid Services (CMS) for this deficiency.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 19.1.6.1, 9.7.2.1., 9.7.2.2, 9.6.1.4, NFPA 13-1999 Standard for the Installation of Sprinkler Systems, NFPA 72 National Fire Alarm Code

10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based on observations, record review and staff interview, the facility failed to ensure that all fire sprinklers and associated components were maintained in good repair, properly installed, and/or maintained free of foreign material.

The findings include, but are not limited, to the following:

a) During the survey, sprinklers were found to be improperly installed in the following locations:

- On 09/29/14 at 10:43AM in the Clergy Vestment Storage Closet in the Chapel on the 1st Floor of the "1955" Building, an upright sprinkler was improperly installed in the pendent position.

- On 09/29/14 at 11:50AM an escutcheon of a sprinkler in a Toilet Room in the 1st Floor Sleep Lab Room #1 in the "1955" Building was noted to be in disrepair. In addition, the deflector of a sprinkler in Sleeping Suite #1 was found to be located above the suspended ceiling.

- On 09/30/14 at 8:15AM an upright sprinkler was found to be improperly installed in the sidewall position in the interstitial space above the suspended ceiling in the "Radio Room" next to the Board Room on the 1st Floor of the "1955" Building.

- On 09/30/14 at 8:34AM a sidewall sprinkler was found to have been improperly installed upside down in a skylight in the Main Waiting Room of the facility on the 1st Floor of the "1955" Building.

- On 09/30/14 at 9:06AM two (2) pendent sprinkler s were found to be improperly installed in the upright position in the Balance Room on the 1st floor of the "1955" Building.

- On 09/30/14 at 9:46AM a pendant sprinkler was found to have been improperly installed in the sidewall position inside the C-Wing Linen Chute Room in the 1st Floor of the "1955" Building.

- On 09/30/14 at 10:54AM six (6) pendent sprinklers in the interstitial space above the suspended ceiling in the Basement Linen Storage Room (this space had formally been a Training Room) in the "1955" Building were found to have been improperly installed in the upright position.

- On 09/30/14 at 11:20AM the deflector of an upright sprinkler in the exterior loading dock of the "1955" Building had less than one (1) inch of clearance (e.g., approximately three quarters {¾} of an inch)from the ceiling in this area. At least one (1) inch of clearance is required.

- On 09/30/14 at 11:35AM supports for a pipe that served a heat pump in the Main Boiler Room in the Basement of the "1955" Building was found to be improperly attached to overhead sprinkler piping. Sprinkler piping is not permitted to be used to support equipment or systems that are not related to the sprinkler system.

- On 10/01/14 at 9:21AM, the Toilet / Shower Room in the Physicians' On-Call Suite in the Basement of the "1955" Building was noted to lack required sprinkler protection. A pendent sprinkler was found to have been installed above the suspended ceiling in this room but would be unable to provide adequate protection for this room.

- On 09/30/14 at 2:20PM supports for three (3) different light fixtures in the Basement Medical Records Mechanical / Sprinkler Equipment Room the "1977" Building were found to be improperly attached to overhead sprinkler piping. Sprinkler piping is not permitted to be used to support equipment or systems that are not related to the sprinkler system.

On 09/30/14 at 2:38PM five (5) sprinklers in a Basement corridor (the "Respiratory" corridor) in the "1955" Building were noted to have deflectors that were located above the suspended ceiling (e.g., these sprinklers need to be lowered).

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken immediately.

b) During the survey, sprinklers were found to be missing required escutcheon cover plates and/or escutcheons in the following locations:

- On 09/29/14 at 11:39AM in a Janitor's Closet on the 1st Floor of the "1977" Building (near the Entrance to the CCU {Critical Care Unit}) a sprinkler was missing its escutcheon.

- On 09/30/14 at 2:30PM two (2) sprinklers in a Basement Medical Records Room in the "1977" Building were noted to be missing escutcheons.

- On 10/01/14 at 8:52AM a sprinkler in a Basement Mechanical Equipment Room (across from the M.I.S. Storage Room) in the "1955" Building was noted to be missing.

- On 10/01/14 at 11:07AM a sprinkler was noted to be missing an escutcheon cover plate in the Basement level landing of the staircase to the Basement in the A-Wing of the "2001" Building.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken immediately.

c) During the survey sprinkler water discharge pattern development was found to be either obstructed, or areas were found to have inadequate sprinkler protection in the following locations:

- On 09/29/14 at 11:41AM only one (1) sprinkler was found to be installed in an "L" shaped room in the Splint Storage Room on the 1st Floor of the "1977" Building. The way that the walls of this room are arranged, and where the single sprinkler is located, the sprinkler would be unable to provide complete protection of this room.

- On 09/30/14 at 11:39AM the discharge pattern of a pendent sprinkler located in "Frank's Locked Storage Room" in the Basement of the "1955" Building was noted to be partially obstructed by a light fixture.

- On 09/30/14 at 12:18PM the discharge pattern of two (2) pendent sprinklers located in the Elevator Machine Room in the Basement of the "1955" Building were noted to be partially obstructed by a light fixture.

- On 09/30/14 at 1:40PM only one (1) sidewall-type sprinkler was provided in the bottom of the Elevator shaft that serves the Hydraulic Elevators in the A-Wing of the "2001" Building and it was unclear at the time of the inspection that this single sprinkler could provide adequate protection of the Elevator shaft.

- On 10/01/14 at 9:06AM a portion of a Basement Mechanical Equipment Room (i.e., Sprinkler Zone Valve 3 Room) in the "1955" Building lacked complete sprinkler protection.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken immediately.

d) During the survey, foreign materials (e.g., paint, joint compound, or firestopping caulk) were noted on sprinklers or sprinkler escutcheon cover plates in the following locations:

- On 09/29/14 at 11:56AM in Sleeping Suite #2 on the 1st Floor of the "1955" Building, paint was noted on two (2) of the sprinklers in this room.

- On 09/30/14 at 1:52PM a sprinkler in the Pharmaceutical Waste Storage Room in the Basement of the "1955" Building was noted to have a foreign material (e.g., joint compound) on it.

- On 09/30/14 at 2:38PM seven (7) sprinklers in a Basement corridor (the "Respiratory" corridor) in the "1955" Building were noted to have a foreign material (e.g., paint) on them.

- On 10/01/14 at 8:47AM two (2) sprinklers in a Basement Pneumatic Tube Room in the "1955" Building were noted to have a foreign material (e.g., one {1} with firestopping caulk and the other with joint compound) on them.

- On 10/01/14 at 8:48AM a sprinkler in the bottom landing of an Exit stair from the Basement of the "1955" Building (located by the Pneumatic Tube Room) was noted to have a foreign material (e.g., joint compound) on it.

- On 10/01/14 at 9:06AM a sprinkler in the Basement Laboratory Staff Break Room in the "1955" Building had a foreign material (e.g., joint compound) on it.

- On the afternoon of 10/02/14 the escutcheon cover plates of four (4) out of four (4) sprinklers in Operating Room #1 and four (4) out of four (4) sprinklers in Operating Room #2 on the 2nd Floor of the A-Wing in the "2001" Building were noted to have a foreign material (e.g., paint) on them.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken immediately.

e) On the afternoon of 10/02/14 review of the 08/05/14 "Automatic Sprinkler Systems Annual Inspection, Tests, and Maintenance" Report prepared by the facility's outside Vendor responsible for inspecting, testing, and maintaining the sprinkler system, stated that the Vendor "physically inspected the fire sprinkler system" but did not note any deficiencies with the sprinkler system during his inspection. NFPA 25 requires that "Sprinklers be inspected from the floor level annually. Sprinkles shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-1, Table 2-1

10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based on observations and staff interviews, the facility failed to ensure that automatic sprinkler systems were maintained in accordance with the requirements found in NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

The findings include, but are not limited to, the following examples:

a) On the morning and afternoon of 09/30/14 sprinkler system pressure gauges in several locations (e.g., the "1955" Building Basement Boiler / Sprinkler Zone #2 Room, the "1955" Building Basement Respiratory Therapy Offices / Sprinkler Zone #5 Room and the "1977" Building Basement Medical Records Area Mechanical Room / Sprinkler Zones #6A and #6B), were labeled that they were manufactured in 1996. As per interview with the facility's Director of Engineering on 09/30/14 at 11:01AM, he was not sure when the sprinkler Vendor who maintains the sprinkler system replaced or tested sprinkler system pressure gauges.

On the morning of 10/02/2014, record reviews revealed that the facility did not have any records pressure gauge calibration or replacement. Pressure gauges are required to replaced or recalibrated once every five (5) years). As per interviews with the facility's Director of Engineering at 1:15PM, he is trying to obtain these documents from the Vendor who maintains the sprinkler system.

b) On 10/01/14 at 8:55AM sprinkler protection was noted to be provided in the interstitial space above the suspended ceiling in the Basement of the "1955" Building (in the corridor by the Laboratory Wing). As per concurrent interview with the facility's Director of Engineering, these sprinklers may date back to the original construction of this Building (e.g., 1955). He said he will check with the facility's sprinkler Vendor to determine the exact act of these sprinklers and if they need to be replaced or retested due to their age.

c) On the morning of 10/02/14 a sprinkler system Post Indicator Control Valve located on the South side of the facility (outside of the Emergency Room Entrance, near Hempstead Turnpike) and a sprinkler system Post Indicator Control Valve located on the West side of the facility (outside of the Coffee Shop) was noted to lack signage which would indicate what sprinkler zones they controlled. All control, drain and test connection valves are required to be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means. As per interview with the facility's Director of Engineering on 10/02/14 at 10:25AM, he will have required identification signage installed as soon as possible.

d) On 10/01/14 at 11:24AM it was noted the Spare Sprinkler Storage Cabinet in the A-Wing Basement Boiler / Mechanical Equipment / Fire Pump Room in the "2001" Building lacked one (1) spare upright, one (1) spare sidewall and two (2) spare dry-head sprinklers. NFPA 25-1998 Chapter 2-4.1.4 requires that "A supply of at least six (6) spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two (2) sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100°F (38°C)." As per concurrent interview with the facility's Director of Engineering, he will ensure that the Vendor responsible for maintaining the sprinkler system provides an adequate supply of spare sprinklers.

e) On the afternoon of 10/02/14 record review revealed that the facility did not have any records for the following items that are supposed to be conducted every five (5) years on the sprinkler system: inspection of alarm and check valve and obstruction investigation. As per interviews with the facility's Director of Engineering at 1:15PM, he is trying to obtain these documents from the Vendor who maintains the sprinkler system.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 19.7.6, 9.7.5, 4.6.12, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-1, Table 2-1, 9-1, Table 9-1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interview, the facility did not ensure that vertical ventilation ducts in the Building were protected in accordance with NFPA 90A.

Findings:

On 09/29/14 at 10:05AM a ceiling exhaust ventilation duct opening in the T-Wing Nurses' Station Crash Cart / Oxygen Tank Storage Alcove on the 1st Floor of the "1955" Building was not properly enclosed by ductwork. There is an approximately five (5) inch gap between the duct opening in the suspended ceiling and the exhaust ventilation duct that it is supposed to be attached to.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.2.1, 9-2, NFPA 90A-1999, Standard for the Installation of and ventilating Systems: 2-3.5.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interview, the facility failed to ensure that required placards identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system were conspicuously placed near each portable fire extinguisher in Cooking Areas.

Findings:

On 09/30/14 at 9:45AM the facility was found to lack the required placard (sign) identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system near the portable "K" type fire extinguishers in the 1st Floor Coffee Shop Food Preparation / Cooking Area on the 1st Floor of the "1955" Building. The required placard shall state "WARNING: In case of appliance fire use this extinguisher after fixed suppression system has been used". As per concurrent interview with the facility's Director of Engineering, he will have the required placard installed as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96-1998 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 7-2.1.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interviews, the facility failed to ensure that means of egress were continuously maintained free of all obstructions or impediments to full and instant use in case of fire or other emergency.

Reference is made to the following:

On 10/01/14 at 11:32AM a filing cabinet filled with fan belts was found to be improperly stored at the Rooftop Level landing of the North Exit Staircase in the A-Wing of the "2001" Building. As per concurrent interview with the facility's Director of Engineering, this filing cabinet should not be stored inside an Exit enclosure and he will instruct one of his staff to remove the filing cabinet immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.2.1, 7.1.10.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interviews, the facility failed to ensure that piped oxygen was not piped to, or used for, any purpose except for use in patient care applications.

Findings:

On 09/30/14 at 9:50AM an oxygen supply outlet located in a former Labor/Delivery Room that had been converted into an Emergency Preparedness Supply Storage Room was noted to be leaking. As per concurrent interview with the facility's Director of Engineering, immediate corrective action will be taken.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 12-3.4.1, Ch. 4
10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based on observations and staff interviews, the facility failed to ensure that where extinguishment or control of fire is effectively accomplished by a type of automatic extinguishing system other than an automatic sprinkler system, such as Halon 1301, that such systems shall be installed, inspected and maintained in accordance with appropriate NFPA standards.

Findings:

a) On 09/29/14 at 10:50AM the CAT Scan Room on the 1st Floor of the "1955" Building was found to be protected by a Halon System. The door from the CAT Scan Room to the adjacent CAT Scan Control Room lacked a self-closing or automatic closing device. In addition, the self-closing device on the door from the CAT Scan Room into the Radiology Suite was found to be broken and did not function properly. In order to prevent loss of agent through openings to adjacent hazards or work areas, openings, such as these doors, shall be permanently sealed or equipped with automatic closures. As per concurrent interview with the facility's Director of Engineering, he takes corrective action immediately.

b) On 09/30/14 at 2:58PM the Main Computer Server Room in the Basement of the "1955" Building was found to be protected by a Halon System. A Closet that contains the Halon System tank opens directly into the Server Room and lacks a self-closing device. In addition, the enclosure walls that separate this Closet from the adjacent Server Room had an unsealed cable penetration and the Closet lacked sprinkler protection and did not appear to be protected by the Halon System (e.g., no nozzle was provided in this Closet). As per concurrent interview with the facility's Director of Engineering, he will take corrective action immediately.

42 CFR 482.41 (b), NFPA101-2000 Life Safety Code: 9.7.3, NFPA 12A, Standard on Halon 1301 Fire Extinguishing Systems: 3-3.1.2, 4-1.1

10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based on observations and staff interview, the facility did not ensure that Exiting from all assembly use areas was in compliance with all of the requirements found in NFPA 101.

Findings:

On 09/29/14 at 3:07PM the Staff Dining Room in the Basement of the "1955" has an occupant load greater than fifty (50) people (e.g., ninety-six {96} people). The doors to this room were noted to open into the room and did not swing in the direction of exit travel. Doors in rooms or areas that have more than an occupant load of fifty (50) are required to swing in the direction of exit travel. As per concurrent interview with the facility's Director of Engineering, he will take corrective action as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 13.2.1, 7.2.1.4.2

10NYCRR, 405.24 (b), 711.2 (a) (1)


3. Based on observations and staff interview, the facility failed to ensure that the standpipe system was properly maintained.

Findings:

On the morning of 10/01/14 it was noted that standpipe system hose connection caps were missing in several locations (e.g., at rooftop standpipe in the South Exit Stair) in the A-Wing of the "2001" Building. As per interview with the facility's Director of Engineering on 10/01/14 at 11:39AM, the facility has had chronic problems with the hose connection caps being stolen. It was recommend by the Surveyors that the facility replace the missing brass caps with less valuable plastic caps.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 9.7.5, NFPA 25-1998, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 3-1, 3-2.3, Table 3-2.3

10NYCRR, 405.24 (b), 711.2 (a) (1)


4. Based on observations, record review and staff interviews, the facility failed to ensure that required two (2) hour fire resistance rated separation was maintained between the Existing Health Care Occupancy on the 1st Floor of the "1955" Building and the Existing Business Occupancy and Existing Storage Occupancy located in the Basement of the "1955" Building.

Findings:

Multiple observations made during the survey on 09/29/14, 09/20/14 and 10/01/14 revealed that the single story plus Basement "1955" Building was of Type V (000) Unprotected Combustible construction due to the use of unprotected wood structural members throughout the building. This is a permitted construction type for a single story Existing Health Care Occupancy provided that the building is provided that the building is provide throughout by a supervised, automatic sprinkler system. During the survey it was noted that sprinkler were missing from a couple of required locations in the "1955" Building and that the sprinkler system also lacked required supervisory devices on all sprinkler control valves (see K56 and K62 for additional information). NFPA 101-2000 Section 19.1.2.3 requires that health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two (2) hours as provided for additions in Section 19.1.1.4.

Record review (Life Safety Floors Plans for the facility dated 01/22/14) and staff interviews on the morning of 09/29/14 revealed that different sections / use areas of the Basement of the "1955" Building were classified as either Existing Business Occupancy or Existing Storage Occupancy.

Observations revealed that there was no two (2) hour fire resistance rated horizontal barrier to separate the Basement of the "1955" Building from the 1st Floor. Examples include:

- On 09/30/14 at 10:50AM an approximately eight (8) inch by four (4) foot hole was noted in what had been a rated ceiling assembly in a basement Linen Department Office/Storage Area.

- On 09/30/14 at 11:08AM an approximately ten (10) foot by four (4) foot hole, an approximately twelve (12) inch by twelve (12) inch hole, and an approximately eighteen (18) inch by six (6) inch hole were noted in what had been a rated ceiling assembly in a Basement Environmental Services Office.

- On 09/30/14 at 11:15AM the Basement Exit access corridor located outside of the Environmental Services Office was noted to lack any fire resistance rated ceiling assembly (it appears that if there ever was a fire resistance rated ceiling assembly in this corridor that it had been removed at some point in the past).

- On 09/30/14 at 12:03PM an approximately eight (8) inch by six (6) inch hole was noted in what had been a rated ceiling assembly in a Basement Kitchen Dry Goods Storage Area.

- 09/30/14 at 12:12PM an approximately three (3) inch by five (5) inch hole was noted in what had been a rated ceiling assembly in a Basement Plumbing Supply Storage Room.

- On 09/30/14 at 12:20PM the Basement Exit access corridor located outside of the Elevator Lobby and the Pharmacy Area was noted to lack any fire resistance rated ceiling assembly (it appears that if there ever was a fire resistance rated ceiling assembly in this corridor that it had been removed at some point in the past).

- On 10/01/14 at 8:35AM the Basement Exit access corridor located outside of the Laboratory Area was noted to lack any fire resistance rated ceiling assembly (it appears that if there ever was a fire resistance rated ceiling assembly in this corridor that it had been removed at some point in the past).

- On 09/30/14 at 9:32AM several different sized holes were noted in what had been a rated ceiling assembly in a Basement Lab Formaldehyde Storage Room.

As per interviews with the facility's Director of Engineering and the Corporate Life Safety Director on 10/02/14 at 10:10AM, they will probably request a Waiver for the lack of a two (2) hour fire resistance rated ceiling assembly in the Basement of the "1955" Building based on the building having complete automatic sprinkler protection.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.1.6.2, Table 19.1.6.2, 19.1.2.3, 19.1.1.4, 8.2.3

10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based on observations and record (i.e., Panel Board Schedule / Circuit Directory) reviews, and staff interviews during the survey, the facility was not provided with a Type 1 Essential Electrical System that was divided into separate Critical Branch, Life Safety Branch and Equipment Systems in accordance with NFPA 99. In addition, the facility failed to ensure that normal service wiring was separated from emergency service wiring. These deficiencies were noted in existing areas of the facility.

The findings include, but are not limited, to the following:

a) On 09/29/14 at 11:15AM review of the Emergency Power Panel Directory for Panel "EM0006 (CR)" on the 1st Floor of the "1955" Building revealed that this Panel served both Emergency System-Critical Branch Loads (e.g., room receptacles) and Equipment System Loads (e.g., rooftop air conditioning unit). As per concurrent interview with the facility's Director of Engineering, the facility has an ongoing project to upgrade the facility's Emergency Power System so that it meets Type 1 Essential Electrical System requirements. He also said that he has an approved Waiver for the lack of a Type 1 Essential Electrical System from the New York State Department of Health and an approved Time-Limited Equivalency for the lack of a Type 1 Essential Electrical System from the Joint Commission.

b) On 09/29/14 at 12:32PM review of the Emergency Power Panel Directory for Panel "EM0028" on the 1st Floor of the "1955" Building revealed that this panel served both Emergency System-Life Safety Branch Loads (e.g., fire alarm strobes) and Emergency System-Critical Branch Loads (e.g., receptacles, exhaust fan).

c) On 09/29/14 at 1:55PM review of the Emergency Power Panel Directory for Panel "EM0012" on the 1st Floor of the "1955" Building revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit sign) and Emergency System-Critical Branch Loads (e.g., receptacles, x-ray).

d) On 09/29/14 at 2:02PM review of the Emergency Power Panel Directory for Panel "EM0020" on the 1st Floor of the "1955" Building revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Alarm power booster, lights) and Emergency System-Critical Branch Loads (e.g., receptacles).

e) On 09/29/14 at 2:38PM observations in the 1st Floor MRI Unit Electrical Room revealed that wiring from Emergency System-Critical Branch Panel "1E-CR" was improperly run into the same metal raceway containing wiring from Emergency System-Life Safety Branch Panel "1E-LS" without any physical separation between the wiring from the two (2) different branches. Wiring from the Emergency System-Critical Branch is required to be kept separate from the Emergency System-Life Safety Branch. In addition, in the same room, wiring from Emergency System Panel "1E-EQ" and wiring from Normal Power Panel Board "1N" are also run through a common raceway.

f) On 09/30/14 at 8:20AM review of the Emergency Power Panel Directory for Panel "EM0040" on the 1st Floor of the "1955" Building revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit signs and lights) and Emergency System-Critical Branch Loads (e.g., receptacles, Nurse Call System, Argon Laser).

g) On 09/30/14 at 9:35AM wiring for Emergency System-Critical Branch duplex receptacles was not separated from Normal Power System duplex receptacles in quad receptacles boxes in the 1st Floor M-Wing Orthopedic Equipment Storage Room in the "1955" Building. There is no physical separation (e.g., a barrier) to separate the Emergency System wiring from the Normal power wiring. As per concurrent interview with the facility's Director, separation of Normal from Emergency System wiring is part of the facility's ongoing Electrical System upgrade / modernization project.

h) On the morning of 09/30/14 review of the Emergency Power Panel Directory for Panel "EM0014" on the 1st Floor of the "1955" Building revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit stairway lighting, Exit access corridor lighting, the Intercom System) and Emergency System-Critical Branch Loads (e.g., receptacles, task lighting, Isolation Room fans).

i) On the morning of 09/30/14 review of the Emergency Power Panel Directory for Panel "EM0082" in the Basement Kitchen of the "1955" Building revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit signs, Alarm relays) and Equipment System Loads (e.g., coffee machine).

j) On 09/30/14 at 2:00PM in the Basement Generator / Electrical Room (in the Medical Records Wing of the "1977" Building) wiring from Emergency System-Life Safety Branch Panel "EELS-0104", Emergency System-Critical Branch Panel "GECR-0111" and Equipment System Panel "EEEQ-0112" were noted to run from separate conducts into a common electrical junction box. In addition, an electrical conduit is this room was connected to both duplex receptacles (an Emergency System-Critical Branch Load) and an Exit sign and emergency lighting fixture (Emergency System-Life Safety Branch Loads).

k) On 09/30/14 at 2:28PM in the Basement CCU (Critical Care Unit) Mechanical Room (in the Medical Records Wing of the "1977" Building), wiring that served the Medical Air System Local Carbon Monoxide and Dew Point Alarms was found to be powered by an electrical conduit that was labeled "GECR Circuits 21, 23". Panel "GECR" is an Emergency System-Critical Branch Panel but NFPA 99 requires that Local, Area and Master Gas Alarm Systems be "powered from the Life Safety Branch of the Emergency System". As per concurrent interview with the facility's Director of Engineering, he will notify his consultant Electrical Engineer about this issue.

l) On 10/01/14 at 9:10AM review of the Emergency Power Panel Directory for Panel "EM0102" in the Basement Laboratory Stock Room in the "1955" Building revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit signs, lights) and Emergency System-Critical Branch Loads (e.g., Laboratory refrigerator and receptacles, Wire Mold Lab.).

m) On 10/01/14 at 10:58AM review of the Emergency Power Panel Directory for Panel "LC-CR-MS-Sect 2" in a 1st Floor Electrical Room (near Janitor's Closet #S135) in the S-Wing of the "2001" Building revealed that this Panel served Emergency System-Life Safety Branch Loads (e.g., fire smoke dampers), Emergency System-Critical Branch Loads (e.g., Nurse Call System, receptacles, pneumatic tube, corridor receptacles) and Equipment System Loads (e.g., heat trace).

n) On 10/01/14 at 12:31PM observations in the A-Wing 1st Floor Electrical Closet A131A in the "2001" Building revealed that wiring from Emergency System-Critical Branch Panel "LP-CR-1A1 Sect.2" was improperly run into the same metal raceway as well as a conduit containing wiring from Normal Power Panel "LP1A Sect. 1" without any physical separation between the wiring from the two (2) different branches.

o) On 10/01/14 at 1:54PM review of the Emergency Power Panel Directory for Panel "EDP-OR" in a 2nd Floor Electrical Room (by the Elevator Lobby) in the A-Wing of the "2001" Building revealed that this Panel served Emergency System-Life Safety Branch Loads (e.g., fire smoke dampers) and Emergency System-Critical Branch Loads (e.g., Operating Room receptacles). In addition, review of the Emergency Power Panel Directory for Panel "LP-CR-2B" in the above-mentioned Electrical Closet revealed that this Panel served Emergency System-Critical Branch Loads (e.g., Operating Room lights, pneumatic tube, a medication refrigerator and Holding Area receptacles) and an Equipment System Load (e.g., hot water heater).

p) On the morning of 10/02/14 review of Waiver / Equivalency Documents that the facility had been previously issued revealed that:

- The New York State Department of Health had, on 01/15/02, granted a Waiver to the facility for the lack of a Type 1 Essential Electrical System in the "2001" Building. Approval of this Waiver was contingent on the facility developing a documented Preventative Maintenance Program that meets the requirements of NFPA 110, Standard for Emergency and Standby Power Systems. This deficiency was noted during the 11/07/01 Pre-Occupancy Inspection of the "2001" addition to the facility. No expiration date was provided on this Waiver.

- The New York State Department of Health had, on 02/27/08, granted a Waiver to the facility for the lack of a Type 1 Essential Electrical System in the "1955" Building. Approval of this Waiver was contingent on the facility developing a Master Plan to upgrade the Emergency Power System to comply with the required regulations. This deficiency was noted during the 01/07/08 Pre-Occupancy Inspection of the Hyperbaric / Wound Care Unit Construction Project in the "1955" Building. No expiration date was provided on this Waiver.

- The Joint Commission had, on 09/05/08, issued an Equivalency for the lack of a Type 1 Essential Electrical System. Approval of this Equivalency was contingent on the facility providing annual updates on the progress of their Master Plan to upgrade / modernize the facility's Emergency Power System. This Equivalency has an expiration date of 10/01/18. The facility provided records of the annual updates that they submitted to the Joint Commission in 2009, 2010, 2011, 2012 and 2013.

On 10/02/14 at 10:00AM the facility's Director of Engineering and their Corporate Life Safety Director were informed that while they may have been issued Waivers from the Department of Health, and a Time-Limited Equivalency from the Joint Commission, they would need to submit a Waiver Request to the Centers of Medicare and Medicaid Services (CMS) for this deficiency.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9

10NYCRR, 405.24 (b), 711.2 (a) (1), 711.2 (a) (20)
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1. Based on observations and staff interview, the facility failed to ensure that electrical wiring was installed in a neat and workman like manner or maintained in good repair and that unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings were effectively closed to afford protection substantially equivalent to the wall of the equipment were provided in accordance with the requirements of the NFPA 70, National Electrical Code.

Findings:

a) On 09/29/14 at 9:50AM the housing of a Ground Fault Circuit Interrupter (GFCI) duplex receptacle in the Toilet Room of the T-Wing Staff Lounge on the 1st Floor of the "1955" Building was noted to be cracked.

b) On the morning 09/29/14 grounding pins from electrical plugs were found to have broken off inside of a corridor receptacle outside of Room T1 and in Storage Room T2 on the 1st Floor of the "1955" Building.

c) On 09/29/14 at 11:20AM the housing of a duplex receptacle in a wall of the Step-Down Unit (near Cubicle #1 and the Exit stair) on the 1st Floor of the "1977" Building was noted to be cracked.

d) On 09/30/14 at 9:45AM on the 1st Floor of the "1955" Building, a duplex GFCI receptacle located next to the grill in the Coffee Shop Food Preparation / Cooking Area was noted to have a very heavy build-up of grease on its exposed surfaces.

e) On 09/30/14 at 11:25AM in the Basement Dietary Compressor Machine Room in the "1955" Building, electrical wiring (a "BX" type cable) was found to have been improperly run up through a vertical ventilation system duct within this room. In addition, an open (i.e., uncovered) electrical wiring raceway and an open (i.e., uncovered) electrical junction box were also noted in this room.

f) On 09/29/14 at 2:13PM in the Basement of the "1977" Building, a duplex receptacle in a Medical Records Department Office was noted to be missing a cover plate.

g) On 10/01/14 at 12:05PM on the 1st Floor of the A-Wing in the "2001" Building, the plastic cover plate of a duplex receptacle in Emergency Department "Cardiac Room 1" was noted to be damaged (bent out of shape).

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken immediately. Many of the damaged receptacles were noted to have been replaced prior to the end of the survey.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12

10NYCRR, 405.24 (a) (1), 405.24 (e) (1), 405.24 (b), 711.2 (a) (1)


2. Based on observations and staff interview during the survey, the facility failed to ensure that all Panel Board circuits and circuit modifications were legibly identified as to purpose or use on a Circuit Directory located on the face or inside of the Panel doors in accordance with the requirements of the NFPA 70, National Electrical Code.

Findings:

a) On 09/29/14 at 11:27AM Normal Power Panel "PP-EM2A" by the Nurses' Station in the Step Down Unit on the 1st Floor of the "1977" Building was noted to lack a Circuit Directory.

b) On 09/29/14 at 12:30PM Normal Power Panel "LP-1P" on the 1st Floor of the "1955" Building was noted to have several circuits (e.g., Circuits #3, #4, #6, #8 and #10) on the Circuit Directory in which their function was only identified as "In Use". The specific purpose that these circuits serve are required to be identified.

c) On 10/01/14 at 9:10AM in the Basement of the "1955" Building, Emergency Power Panel "EM0102" was noted to have several circuits (e.g., Circuits #16, #18, #20, #22 and #24) on the Circuit Directory in which their function was only identified as "In Use". The specific purpose that these circuits serve are required to be identified.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13

10NYCRR, 405.24 (b), 711.2 (a) (1)


3. Based on observations and staff interview, the facility failed to ensure that listed tamper resistant electrical receptacles were provided in the Pediatric Treatment Area.

Findings:

On 09/29/14 at 8:50AM on the 1st Floor of the "1955" Building, three (3) duplex electrical receptacles in the Speech and Swallowing Unit Pediatric Treatment Area were noted to not be listed tamper-resistant receptacles. As per concurrent interview with the facility's Director of Engineering, he will have listed tamper-resistant receptacles installed as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 517-18 (c)

10NYCRR, 405.24 (b), 711.2 (a) (1)


4. Based on observations and staff interviews, the facility failed to ensure that flexible cords and cables were not used as a substitute for the fixed wiring of a structure.

Findings:

a) On 09/30/14 at 9:10AM in the B-Wing Nurses' Station on the 1st Floor of the "1955" Building, two (2) relocatable power taps (e.g., "surge protectors") were found to be improperly attached in sequence to each other (i.e., "daisy chained"). The facility's Director of Engineering said that he will try to have additional duplex electrical receptacles installed in this area so that electrically powered equipment can be properly connected directly to fixed wiring.

b) On 09/30/14 at 9:12AM in the B-Wing Case Manager's Office on the 1st Floor of the "1955" Building, two (2) relocatable power taps (e.g., "surge protectors") were found to be improperly attached in sequence to each other (i.e., "daisy chained"). The facility's Director of Engineering said that he will try to have additional duplex electrical receptacles installed in this area so that electrically powered equipment can be properly connected directly to fixed wiring.

c) On 09/30/14 at 2:16PM in the Basement of the "1977" Building, B-Wing a relocatable power tap (e.g., "surge protector") was found to be improperly attached in sequence to an extension cord (i.e., "daisy chained"). The facility's Director of Engineering said that he will try to have additional duplex electrical receptacles installed in this area so that electrically powered equipment can be properly connected directly to fixed wiring.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3, 400-8

10NYCRR, 405.24 (b), 711.2 (a) (1)


5. Based on observations and staff interview during the survey, the facility failed to ensure that a Ground Fault Circuit Interrupter (GFCI) protected receptacle was installed in close proximity (i.e., within six {6} feet) of sinks or similar locations where the electrical receptacle may be subject to wetting.

Findings:

On 10/01/14 at 2:30PM on the 2nd Floor of the A-Wing in the "2001" Building, a duplex receptacle that was not a Ground Fault Circuit Interrupter (GFCI) protected receptacle was found to have been installed only twenty (20) inches from an Emergency Eye Washing Station. As per concurrent interview with the facility's Director of Engineering, the above-mentioned receptacle will be replaced by a Ground Fault Circuit Interrupter (GFCI) protected receptacle as soon as possible.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 210-8 (b)

10NYCRR, 405.24 (a) (1), 405.24 (b), 711.2 (a) (1)


6. Based on observations and staff interview during the survey, the facility failed to ensure that all Critical Care Areas were provided with receptacles from both the Emergency System-Critical Branch and the Normal Power System.

Findings:

On 10/01/14 at 2:38PM on the 2nd Floor of the A-Wing in the "2001" Building, all of the electrical receptacles in A223-Operating Room #1 were found to be served by the Emergency System-Critical Branch. As per concurrent interview with the facility's Director of Engineering, he will have a Normal Power System receptacle installed in this location as soon as possible.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 517-19 (a)

10NYCRR, 405.24 (a) (1), 405.24 (b), 711.2 (a) (1)
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