HospitalInspections.org

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Based on observations and interviews during the survey, the facility failed to ensure that corridors in New Health Care Occupancies were separated from all other areas, including patient areas, by partitions complying with Sections 18.3.6.2 through 18.3.6.5.

Findings:

On 02/21/14 at 11:52AM, the Room HJ-823 - Child Life Room (i.e., the Pediatric Unit Play Area) on the newly renovated 8th Floor Unit in the Hospital for Joint Diseases Building was found to not be separated from exit access corridors in this partially sprinklered smoke compartment by corridor walls in accordance with NFPA 101, Life Safety Code requirements. The lack of required corridor walls to form a barrier to limit the transfer of smoke could endanger the patients in this Play Room.

As per concurrent interview with the facility's Assistant Director of Engineering, he will notify Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.6.1
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1. Based on observations and interviews during the survey, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 18.3.6.3.2 requires that corridor doors in New 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). Facility building plans that were approved or a building permit was issued, or construction started after March 13, 2003, the building or addition must be surveyed under the 2000 New Health Care Occupancy Chapter. Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings include:

a) On 02/21/14 at 9:07AM, the inactive leaf to a set of double doors to Electrical Equipment Closet HJ-1228C on the 12th Floor of the Hospital for Joint Diseases 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 Assistant Director of Engineering, he will notify Administration concerning this condition.

b) On 02/21/14 at 11:10AM, an electrical equipment closet (Room HJ823B) in the recently renovated 8th Floor Pediatric Rehabilitation Unit in the Hospital for Joint Diseases 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


2. Based on observations and interviews during the survey, 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 to 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 02/21/14 at 9:32AM, the inactive leaf to a set of double doors to Information Technology Equipment Closet HJ-1120A in the Hospital for Joint Diseases 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 Assistant Director of Engineering, he will notify Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.2
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1. Based on observation and interview during the survey, the facility failed to ensure that all vertical penetrations of fire barriers were enclosed with construction having at least a 2-hour fire resistance rating.

Findings:

a) On 02/18/14 at 9:25AM, a door to an elevator shaft way in the 9th Floor of the Tisch Building (vicinity Elevator Lobby Room TH-994) was noted to lack a label indicating that it had at least a ninety (90) minute fire resistance rating.

b) On 02/18/14 at 2:24PM, a vertical plumbing penetration in Tisch Building 14 East Equipment Storage Room TH-1427 was found to be only partially sealed with mineral wool. As per concurrent interview with the facility's Director of Engineering, he will have this penetration completely sealed as soon as possible.

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


2. Based on observation and interview during the survey, the facility failed to ensure that newly constructed Atriums were in compliance with the requirements found in Section 8.2.5.6.

Findings include, but are not limited, to the following:

a) On 02/19/14 at 12:35PM, an unsealed plumbing penetration was found in a 2-hour fire resistance rated fire barrier wall (above cross-corridor doors) in the vicinity of the entrance from the Radiology Department to the newly constructed (May, 2013) Tisch Building Main Lobby Atrium 2nd Floor Elevator Lobby. As per concurrent interview with the facility's Director of Engineering, he will have this penetration completely sealed as soon as possible.

b) On the afternoon of 02/19/14, some of the areas on the 1st Floor of Tisch Building that were open to the Atrium in the Lobby of this building were noted to lack required sprinkler protection (e.g., the "North" corridor that leads to Exit Stair "B" and the connecting corridor that goes from the Atrium space to the entrance to the adjacent Alumni Hall Building. Section 8.2.5.6 requires not only that the Atrium space be provided with sprinkler protection but that the entire building be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. Numerous areas of the Tisch Building were found to lack required sprinkler protection (see K56 and K71).

c) On 02/19/14 at 2:14PM, two (2) unsealed cable penetrations found in a 2-hour fire resistance rated fire barrier wall (above cross-corridor doors) in the vicinity of the entrance from the Tisch Building Atrium space to the entrance to the adjacent Medical Sciences Building. As per concurrent interview with the facility's Director of Engineering, he will have these penetrations completely sealed as soon as possible.

d) On 02/19/14 at 2:25PM, interview with the facility's Director of Engineering revealed that the Atrium area was provided with what he described as a "smoke purge" system but he did not know if this smoke purge/smoke control system would meet the engineered smoke control system requirements for an Atrium and would have to notify hospital Administration of this issue. For newly installed constructed Atriums, such as the one in the Tisch Building, an engineering analysis that demonstrates that the building is designed to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or six (6) feet above the highest floor level of exit access open to the Atrium for a period equal to one and a half (1?) times the calculated egress time or twenty (20) minutes, whichever is greater is required to be performed. In addition, the Atrium smoke control system is required to be independently activated by each of the following: a) the required automatic sprinkler system, and (b) manual controls that are readily accessible to the Fire Department. The facility's Director of Engineering said that the smoke purge system definitely had manual controls but was not sure if could be activated by the sprinkler system as well.

e) On 02/19/14 at 2:29PM, the fire resistance rating identification labels on required fire barrier doors that separate the 1st Floor level of the Tisch Atrium/Lobby Area from the adjacent "Skirball Lobby" of the Schwartz Health Care Center Building were painted over. As per concurrent interview with the facility's Director of Engineering, these fire doors have a ninety (90) minute fire resistance and he will have the paint removed from the fire resistance rating identification labels on these doors as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.1.1, 8.2.5.6
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Based on observations and interview during the survey, the facility failed to ensure that buildings containing New Health Occupancies in health care facilities shall be subdivided by smoke barriers. The Life Safety Code requires buildings be subdivided by smoke barriers as follows:

a) To divide every story used by inpatients for sleeping or treatment into not less than two (2) smoke compartments.

b) To divide every story having an occupant load of fifty (50) or more persons, regardless of use, into not less than two (2) smoke compartments.

c) To limit the size of each smoke compartment required by (1) and (2) to an area not exceeding 22,500 ft2.

d) To limit the travel distance from any point to reach a door in the required smoke barrier to a distance not exceeding 200 ft.

Findings:

On the morning of 02/19/14, it was noted that the 4th Floor of the Tisch Building contained a newly constructed (e.g., opened in June, 2013) Healthcare Occupancy (e.g., Same Day Surgical Admitting Unit) and that no smoke barrier was provided on this floor. In addition, the facility has also renovated other areas of this floor (e.g., Laboratory Suite) in December, 2013 that would have required the construction of a smoke barrier due to having an occupant load for the 4th Floor that was greater than fifty (50). If facility building plans were approved, or a building permit issued, or construction started after March 13, 2003, the building or addition must be surveyed under the 2000 New Health Care Occupancy Chapter. As per concurrent interview with the facility's Director of Engineering, he will notify Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.7.1
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1. Based on observations and interviews during the survey, the facility did not ensure that existing smoke barrier walls were constructed to have at least a ?-hour fire resistance rating.

Findings:

a) On 02/21/14 at 9:25AM, a partially sealed conduit penetration and a partially sealed duct penetration were noted on one (1) side of a smoke barrier wall (above cross-corridor doors that were in the vicinity of Soiled Utility Room HJ-1175) on the 11th Floor of the Hospital for Joint Diseases Building.

b) On the afternoon of 02/21/14 the following deficiencies were found with smoke barrier walls on the 4th Floor of the Hospital for Joint Diseases Building:

-An unsealed conduit penetration (above cross-corridor doors near Staff Toilet Room HJ442B).

-An unsealed cable penetration and a partially sealed plumbing penetration (in Staff Toilet Room HJ442B).

c) An unsealed cable penetration was found in the vicinity of a cross-corridor doorway near C218 Anesthesia Workroom in a smoke barrier on Floor SC2 of the Hospital for Joint Diseases.

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


2. Based on observations and interviews during the survey, the facility did not ensure that newly constructed smoke barrier walls were constructed to have at least a 1-hour fire resistance rating.

Findings:

a) On 02/21/14 at 10:18AM, an approximately 46-inch by 14-inch hole was noted on one (1) side of a smoke barrier wall (in the vicinity of Equipment Storage Room HJ-913B) on the 9th Floor of the Hospital for Joint Diseases Building. The project to renovate this Unit was granted by the New York State Department of Health on 03/04/11. If facility building plans were approved, or a building permit issued, or construction started after March 13, 2003, the building or addition must be surveyed under the 2000 New Health Care Occupancy Chapter. As per concurrent interview with the facility's Assistant Director of Engineering, he will have this hole sealed as son as possible.

b) On 02/21/14 at 10:24AM, three (3) unsealed cable penetrations were noted on one (1) side of a smoke barrier wall (in the vicinity of the bathroom of Room HJ-913) on the 9th Floor of the Hospital for Joint Diseases Building.

c) On 02/21/14 at 10:25AM, six (6) unsealed plumbing penetrations and one (1) unsealed conduit penetration were noted on one (1) side of a smoke barrier wall (in the vicinity of a door to the newly constructed Neuro/TB Rehabilitation Gum -Room HJ-960) on the 9th Floor of the Hospital for Joint Diseases Building

d) On 02/21/14 at 11:15AM, one (1) unsealed cable penetration and one (1) conduit penetration that was sealed with an non-fire resistance rated material (e.g., joint compound) were noted in a smoke barrier (above cross-corridor doors that were in the vicinity of the 8 South Unit Toilet Room HJ-850A) on the 8th Floor of the Hospital for Joint Diseases Building. In addition, it was noted that a pipe was improperly incorporated into the construction of this smoke barrier wall. The project to renovate this Unit was granted by the New York State Department of Health on 03/04/11.

e) On 02/21/14 at 11:35AM, two (2) unsealed cable penetrations were noted in a smoke barrier (in the vicinity of the Pediatric Rehabilitation Unit Day Room HJ-861B) on the 8th Floor of the Hospital for Joint Diseases Building. The project to renovate this Unit was granted by the New York State Department of Health on 03/04/11.

f) On the afternoon of 02/21/14 the following deficiencies were found with smoke barrier walls on the recently renovated 5th Floor of the Hospital for Joint Diseases Building:

-An unsealed cable penetration (above cross-corridor doors near HJ560 ADL Kitchen).

-An approximately 1-inch diameter hole (vicinity of Information Technology Closet HJ521).

g) On 02/25/14 at 9:43AM, the top-of-wall assembly and a duct penetration (above cross-corridor doors near Electrical Equipment Closet C324) on one (1) side of a smoke barrier wall on Floor SC3 in the Hospital for Joint Diseases Building were found to have been improperly sealed with a non-fire resistance rated material (e.g., polyurethane expansion foam).

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.7.3, 18.3.7.1, 8.3
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1. Based on observations and staff interview during the survey, the facility failed to ensure that all door openings from hazardous areas were protected by self-closing, positive latching doors.

Findings:

On 02/19/14 at 11:50AM, the door to a newly constructed 4th Floor Tisch Building Laboratory Storage Area was found to have an inactive leaf that lacked a self-closing device and that lacked approved positive latching hardware (it was provided with manually operated concealed latches at the top of the door only, latches are required at the top and bottom of the door). In addition, it was noted that this inactive leaf had been improperly left in the open position at the time of the inspection. As per concurrent interview with the facility's Director of Engineering, this Laboratory Storage Area was for temporary use only while adjacent areas of the Lab undergo renovation but that we will ensure that Administration is notified concerning this condition.

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


2. Based on observations and staff interview during the survey, the facility failed to ensure that areas that are currently under construction are separated by occupied areas by at least 1-hour fire resistance rated construction.

Findings:

a) On 02/19/14 at 1:59PM, eight (8) unsealed conduit penetrations and two (2) partially sealed cable penetrations were found in corridor wall that separates the 1st Floor Tisch Building Atrium/Lobby Area (vicinity of Exit Stair "B") from adjacent areas of the building that are currently under construction.

b) On 02/19/14 at 2:55PM, an unsealed duct penetration was found in a exit corridor wall that separates the exit passageway that serves Exit Stair "C" on the Ground Floor of the Tisch Building from adjacent areas of the building that are currently under construction.

c) On 02/19/14 at 2:59PM, an cable tray penetration was found in a exit corridor wall that separates the exit passageway that serves Exit Stair "C" on the Ground Floor of the Tisch Building from adjacent areas of the building that are currently under construction.

As per concurrent interview with the facility's Director of Engineering, he will have these penetrations sealed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.7.3, 19.7.9, NFPA 241, Standard for Safeguarding Construction, Alteration, and Demolition Operations


3. Based on observations and staff interview during the survey, the facility failed to ensure that hazardous storage rooms were in New Health Care Occupancies were provided with automatic sprinkler protection enclosed in at least 1-hour fire resistance rated construction or, if less than one hundred (100) square feet in size, with smoke resistant partitions.

Findings include, but are not limited, to the following:

a) On 02/20/14 at 9:50AM, a partially sealed conduit penetration was noted in a wall of Supply Chain Management (Clean Supply Storage Room) Room 1421 on the 14th Floor of the Schwartz Health Care Center Building. As per concurrent interview with the facility's Director of Engineering, he believed that the 14th Floor of this building had been renovated in March, 2008 and that he will have the penetration sealed immediately.

b) On 02/20/14 at 9:55AM, Equipment Storage Room 1411 on the 14th Floor of the Schwartz Health Care Center Building was found to be approximately one hundred thirty-two (132) square feet in size and was not provided with a 1-hour fire resistance rated walls or with forty-five (45) minute fire resistance rated self-closing doors.

c) On 02/20/14 at 10:23AM, Equipment Storage Room HC1307 on the 13th Floor of the Schwartz Health Care Center Building was found to lack required forty-five (45) minute fire resistance rated self-closing doors. For example, the inactive leaf on the door assembly to this room lacked a self-closing device and approved positive latching hardware.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.2.1, Table 18.3.2.1, 8.4, NFPA 80-1999, Standard for Fire Doors and Fire Windows: 2-4.4.5
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Based on observations and staff interview during the survey, the facility failed to ensure that all exit staircases were enclosed with at least 2-hour fire resistance rated construction.

Findings:

On 02/20/14 at 11:58AM, five (5) unsealed plumbing penetrations were found in an enclosure wall of Exit Stair "E" on the 2nd Floor the Schwartz Health Care Center Building. As per concurrent interview with the facility's Director of Engineering, these penetrations will be sealed with approved firestopping materials as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.1.1, 8.2.5.4, 7.1.3.2.1
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Based on observations and staff interview during the survey, the facility failed to ensure that openings into exit enclosures were limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

Findings:

a) On 02/19/14 at 10:43AM, a door from a 7th Floor Mechanical Equipment Room in the Tisch Building was found to open directly into Exit Stair "C". As per concurrent interview with the facility's Director of Engineering, he will notify Administration concerning this condition.

b) On the morning of 02/20/14, doors from a 8th Floor Mechanical Equipment Room in the Schwartz Health Care Center Building was found to open directly into Exit Stair "B" and into Exit Stair "A".
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Based on observations and staff interview during the survey, the facility failed to ensure that exit access is arranged so that exits are readily accessible at all times and that any device or alarm installed to restrict the improper use of a means of egress is designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such a means of egress. If special locking arrangements are made, they must be installed in accordance with Section 7.2.1.6.

Findings:

On the morning of 02/19/14, it was noted that electromagnetic locking mechanisms were installed on doors in the means of egress, including on exit stair doors, on the 9th Floor Pediatric and Pediatric Intensive Care Unit and the 8th Floor Maternity Unit. These locking devices are neither approved delayed-egress locks (which are permitted by Section7.2.1.6.1) nor do these locks meet the listed exceptions to Section 19.2.2.2.4. In addition, the facility cannot apply the "Categorical Waiver" option permitted by the Federal Centers for Medicare/Medicaid Services August 30, 2013 S&C Letter 13-58-LSC because not all of the doors on these floors meet all of the Life Safety Code requirements for doors (e.g., not all doors provided with positive latching mechanisms). As per interview with the facility's Director of Engineering on 02/19/14 at 9:25AM, these locking mechanisms were installed to help prevent the abduction of an infant or child from these Units are designed to automatically unlock upon activation of the building's fire alarm system.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.1, 19.2.2.2.4, 19.2.2.2.5, 19.3.6.3, 7.1.9, 7.2.1.6, Centers for Medicare/Medicaid Services August 30, 2013 S&C Letter 13-58-LSC
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Based on observations and staff interviews, the facility failed to ensure that means of egress shall be illuminated in accordance with Section 7.8. Section 7.8 requires that illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use and that required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 Lux) in any designated area.

Findings:

On 02/18/14 at 10:40AM, a light switch located in an exit access corridor (in the vicinity of the Tisch Building 18th Floor East Mechanical Equipment Room) was noted to turn off all lighting (normal and emergency) within this corridor. As per concurrent interview with the facility's Director of Engineering, he will notify Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.8, 7.8
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Based on observations and staff interviews, the facility failed to ensure that that the paths of travel for all means of egress are provided with emergency illumination from the exit discharge to the public way. The facility shall also ensure that exit discharge emergency lighting is arranged so that a delay of not more than ten (10) seconds occurs and that the failure of one (1) bulb does not leave the area in darkness. In addition, the facility shall either ensure that any High Intensity Discharge (HID) lighting fixtures that are used for emergency lighting has a quick (i.e., less than ten {10} seconds) re-striking capability upon loss of power or that additional emergency light fixtures that are capable of providing emergency lighting within ten (10) seconds are provided.

Findings:

On 02/20/14 at 12:24PM, the Main Staff Entrance/Exit from the 1st Floor of the Schwartz Health Care Center (the exit that discharges onto 1st Avenue) consists of an exterior exit stair and an exterior exit ramp were not provided with required emergency lighting. As per concurrent interview with the facility's Director of Engineering, he will notify Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.9.1, 7.9, NFPA 70-1999 National Electrical Code: 700-16
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1. Based on observations and staff interviews during the survey, the facility failed to ensure that automatic sprinkler protection was provided in all required areas and was installed in accordance with the requirements found in NFPA 13, Standard for the Installation of Sprinkler Systems.

Findings include, but are not limited, to the following:

a) On 02/18/14 at 12:00PM, a sprinkler was found to be installed too close to a soffit wall in Floor SC2 Operating Room 7 in the Hospital for Joint Diseases Building. The sprinkler was installed approximately 2-inches from the wall when NFPA 13 requires a minimum separation between sprinklers and a wall.

b) On 02/21/14 at 9:35AM, an eight (8) bed Patient Care Suite (the "Special Care Unit" Suite HJ-1108) was noted on the 11th Floor of the Hospital for Joint Diseases Building. This Patient Care Suite was noted to lack sprinkler protection. As per concurrent interview with the facility's Assistant Director of Engineering, this Suite had originally been constructed as a Medical/Surgical Bed Unit with patient rooms located off of a corridor but that in the 1990's this space was converted into the current suite configuration. Sections 12-1.1.4, 12-3.5.1, and 1-4.6 of the 1985 Edition of NFPA 101, Life Safety Code that the Federal Centers for Medicare/Medicaid Services referenced at the time that this unit was renovated, required that complete sprinkler protection be installed. Section 4.5.6 of the 2000 Edition of NFPA 101 requires that any fire protection system, building service equipment, feature of protection, or safeguard provided for life safety shall be designed, installed, and approved in accordance with applicable NFPA standards.

c) On 02/21/14 at 10:50AM, an Information Technology Closet (Room HJ925C) in the recently renovated 9th Floor Rehabilitation Unit in the Hospital for Joint Diseases Building (the renovation project was approved by the New York State Department of Health on 03/04/11) was not provided with sprinkler protection. If facility building plans were approved, or a building permit issued, or construction started after March 13, 2003, the building or addition must be surveyed under the 2000 New Health Care Occupancy Chapter. It was noted at the time of the inspection that this closet would not be eligible for the listed exception in NFPA 13 Section 5-13.11 to the installation of sprinkler protection in electrical equipment rooms because this closet is not separated from adjacent areas by a code compliant 2-hour fire resistance rated enclosure. For example, the inactive leaf on the door assembly to this room lacked a required self-closing device.

d) On 02/21/14 at 11:06AM, an Information Technology Closet (Room HJ823C) in the recently renovated 8th Floor Pediatric Rehabilitation Unit in the Hospital for Joint Diseases Building (the renovation project was approved by the New York State Department of Health on 03/04/2011) was not provided with sprinkler protection. If facility building plans were approved, or a building permit issued, or construction started after March 13, 2003, the building or addition must be surveyed under the 2000 New Health Care Occupancy Chapter. It was noted at the time of the inspection that this closet would not be eligible for the listed exception in NFPA 13 Section 5-13.11 to the installation of sprinkler protection in electrical equipment rooms because this closet is not separated from adjacent areas by a code compliant 2-hour fire resistance rated enclosure. For example, the inactive leaf on the door assembly to this room lacked a required self-closing device.

e) On 02/21/14 at 11:57AM, an Information Technology Closet (located near the 8 North Elevator Lobby) in the recently renovated 8th Floor Pediatric Rehabilitation Unit in the Hospital for Joint Diseases Building (the renovation project was approved by the New York State Department of Health on 03/04/11) was not provided with sprinkler protection. If facility building plans were approved, or a building permit issued, or construction started after March 13, 2003, the building or addition must be surveyed under the 2000 New Health Care Occupancy Chapter. It was noted at the time of the inspection that this closet would not be eligible for the listed exception in NFPA 13 Section 5-13.11 to the installation of sprinkler protection in electrical equipment rooms because this closet is not separated from adjacent areas by a code compliant 2-hour fire resistance rated enclosure. For example, the inactive leaf on the door assembly to this room lacked a required self-closing device.

f) On afternoon of 02/21/14, Information Technology Closet HJ521A and Information Technology closet HJ521B in the recently renovated 5th Floor Rehabilitation Unit in the Hospital for Joint Diseases Building lack required sprinkler protection. It was noted at the time of the inspection that this closet would not be eligible for the listed exception in NFPA 13 Section 5-13.11 to the installation of sprinkler protection in electrical equipment rooms because this closet is not separated from adjacent areas by a code compliant 2-hour fire resistance rated enclosure. For example, the inactive leaf on the door assembly to Information Technology Closet HJ521A lacked a required self-closing device.

g) On 02/25/14 at 9:10AM, combination Electrical Equipment Room/ventilation duct shaft way Room C324 in Floor SC3 of the Hospital for Joint Diseases Building was found to lack required sprinkler protection. As per concurrent interview with the facility's Director of Engineering, the smoke compartment this room is located in was recently renovated (e.g., the Central Sterile Unit renovation project).

h) On 02/25/14 at 9:22AM, an Information Technology closet in a recently renovated Floor SC3 smoke compartment in the Hospital for Joint Diseases Building lack required sprinkler protection. It was noted at the time of the inspection that this closet would not be eligible for the listed exception in NFPA 13 Section 5-13.11 to the installation of sprinkler protection in electrical equipment rooms because this closet is not separated from adjacent areas by a code compliant 2-hour fire resistance rated enclosure. For example, the inactive leaf on the door assembly to Information Technology closet lacked a required self-closing device and there were several unsealed able penetrations of walls in this closet.

i) On 02/25/14 at 9:30AM, an Environmental Services (Housekeeping) Storage Closet in a recently renovated Floor SC3 smoke compartment in the Hospital for Joint Diseases Building lack required sprinkler protection.

j) On 02/25/14 at 9:35AM, Biomedical Equipment Cleaning and Storage Room in a recently renovated Floor SC3 smoke compartment in the Hospital for Joint Diseases Building lacked required sprinkler protection. In addition, it was noted that the smoke resistant integrity of walls in this room was compromised due to three (3) unsealed cable penetrations and one (1) unsealed plumbing penetration of walls in this room.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.5.1, 19.1.1.4.5, 9.7.1., 11.8.2.1, 4.5.6, 8.2.3, NFPA 13-1999 Standard for the Installation of Sprinkler Systems: 5-1.1, 5-6.3.3, 5-13.6, NFPA 80-1999, Standard for Fire Doors and Fire Windows


2. Based on observations and staff interviews during the survey, the facility failed to ensure that electronic supervisory devices that would provide a distinctive supervisory signal to indicate a condition or impairment with the automatic sprinkler system were installed on all control valves that serve the automatic sprinkler system. Life Safety Code Section 18.3.5.1 and 19.3.5.1 requires that health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. Section 9.7.1.1 requires that each automatic sprinkler system be installed in compliance with NFPA 13, Standard for the Installation of Sprinkler Systems. In addition, Section 9.7.1.2.1 requires that where supervised systems are required by another section of the Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air-pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

On 02/21/14 at 3:00PM in the Hospital for Joint Diseases Building Exit Stair "A" at the 1st Floor, it was noted a control valve that serves a combination sprinkler/standpipe system were not provided with required electronic supervisory devices (e.g., tamper alarms). As per concurrent interview with the facility's Fire Safety Consultant, the facility is not required to install an electronic supervisory device (e.g., tamper alarm) on this sprinkler system control valve.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.7.1.2.1, NFPA 13, NFPA 72
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1. Based on observations and staff interview during the survey, the facility failed to ensure that all fire sprinklers were maintained free of foreign material.

Findings:

On 02/19/14 at 10:56AM, a build-up of a foreign material (e.g., paint) was noted on an automatic sprinkler in the Tisch Building 6th Floor Operating Room Suite Trash Storage Room. As per concurrent interview with the facility's Director of Engineering, he will have the vendor who maintains the sprinkler system replace this sprinkler as soon as possible.

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: 2-2.1.1


2. Based on observations and staff interview during the survey, the facility failed to ensure that all fire sprinklers and associated components were maintained in good repair.

Findings:

a) On the morning of 02/19/14 in the Tisch Building, recessed sprinklers located in the vicinity of the 5th Floor Female and Male Staff Locker Rooms were noted to be missing required escutcheon cover plates.

b) On 02/19/14 at 3:08PM in the Tisch Building Ground Floor Soiled Linen Chute Discharge Room, a sprinkler pipe support hanger was noted to be in disrepair (i.e., it was no longer attached to the ceiling assembly and was hanging upside down off of the pipe). As per concurrent interview with the facility's Director of Engineering, he will have the vendor who maintains the sprinkler system replace this damaged support bracket as soon as possible.

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
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Based on observations and staff interview during the survey, 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 02/19/14 at 3:07PM, 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 two (2) out of two (2) portable "K" type fire extinguishers in the Tisch Building Ground Floor Main Kitchen Area. 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 placards 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
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1. Based on observations and staff interview during the survey, the facility failed to ensure that Building Service Chutes (e.g., Linen, Rubbish) are protected internally by automatic sprinklers with sprinklers provided above the top service opening of the chute, above the lowest service opening, and above service openings at alternate levels in buildings over two (2) stories in height.

Findings:

On the morning of 02/19/14, inspection of the interior of the Soiled Linen Chute in the Tisch Building revealed that sprinkler protection of the chute was only at the top service opening and the lowest service opening. As per interview with the facility's Director of Engineering on 02/19/14 at 3:08PM, he confirmed that the Soiled Linen Chute was only provided with sprinkler protection at the top level (i.e., 18th Floor) and the lowest level (i.e., the Ground Floor Soiled Linen Chute Discharge Room).

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.4.2, 9.7, NFPA 13-1999, Standard for the Installation of Sprinkler Systems: 5-13.5


2. Based on observations and staff interview during the survey, the facility failed to ensure that building service chutes (e.g., soiled linen, rubbish) were separately enclosed by walls or partitions in accordance with the provisions of Section 8.2.

Findings:

On 02/20/14 at 9:25AM, the Soiled Linen and Rubbish Chutes were found to pass through the East Elevator Machine Room Rooftop Penthouse in the Schwartz Health Care Center Building and neither of these chutes was enclosed by required fire barriers constructed in accordance with Section 8.2. As per concurrent interview with the facility's Director of Engineering, he would notify hospital Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.4.2, 9.5, 8.2
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1. Based on observations and staff interviews during the survey, the facility failed to ensure that no more that three hundred (300) cubic feet of oxygen cylinders were located outside of an enclosure (per smoke compartment) at locations open to the corridor such as at a Nurses' Station or in a corridor of a healthcare facility.

Findings:

On 02/18/14 at 11:24AM, fifteen (15) Type "E" cylinders of oxygen (e.g., approximately three hundred sixty {360} cubic feet of oxygen) were found to be located within a single smoke compartment in the Tisch Building 16 West Urgent Care Unit (vicinity Room TH-1604) and were not stored in a storage location that would meet the requirements found in NFPA 99 Section 8-3.1.11.2 (e.g., no sprinkler protection provided and less that twenty {20} feet separation from combustible materials). As per concurrent interview with the facility's Director of Engineering, he will notify Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 4-3.1.1.2, 8-3.1.11.2, Center for Medicaid and State Operations/Survey and Certification Group S&C-07-10


2. Based on observations and staff interviews during the survey, the facility did not ensure that electrical fixtures in oxygen and oxidizing gas (i.e., nitrous oxide) storage locations were mounted at least sixty (60) inches above the finished floor as a precaution against their physical damage.

Findings:

a) On 02/18/14 at 12:19PM, a duplex electrical outlet in an Oxygen Cylinder Storage Room on the 15th Floor of the Tisch Building was installed at a height of 18-inches above the floor. In addition, this storage location lacked required mechanical exhaust ventilation. As per concurrent interview with the facility's Director of Engineering, he will notify Administration concerning this condition.

b) On 02/20/14 at 11:27AM, a light switch in Oxygen Cylinder Storage Room HC-905B in the 9th Floor of the Schwartz Health Care Center Building was installed at a height of 49-inches above the floor. In addition, this storage location lacked required mechanical exhaust ventilation. As per concurrent interview with the facility's Director of Engineering, he will notify Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 4-3.1.1.2 (a) (4), (c)


3. Based on observations and staff interview during the survey, the facility failed to ensure that where cryogenic oxygen storage is located outside of the building served that an emergency inlet for connecting a temporary auxiliary source of supply for emergency or maintenance situations is provided.

Findings:

As per observations on the morning of 02/25/14, the facility was not noted to have the required emergency oxygen supply inlet. Interview with the facility's Director of Engineering on 02/25/14 at 7:50AM revealed that the bulk oxygen system is a new installation (installed in 2013) and the required emergency inlet has not been installed yet but that it should be installed soon.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 4-3.1.1.8 (h)


4. Based on observations and staff interviews during the survey, the facility failed to ensure that all bulk oxygen storage locations were in compliance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.

Findings:

On 02/25/14 at 9:28AM, the newly installed bulk oxygen system (installed in 2013) was noted to be installed less than fifty (50) feet from a place of public assembly. For example, Coles Student Center Building Lecture Hall CL-109 with a posted maximum allowed occupancy of eighty-six (86) was located immediately adjacent to the bulk oxygen system It was noted that liquid oxygen vaporizers that serve this bulk oxygen system were only approximately fifteen to twenty (15-20) feet from an unprotected window opening into this Lecture Hall. As per concurrent interview with the facility's Director of Engineering, he believed that the facility had been issued waivers for the bulk oxygen system being too close to a place of public assembly by both the New York City Fire Department (FDNY) and the New York State Department of Health. He also said that he will notify Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 4-3.1.1.1 (b) (1), NFPA 50-1996, Standard for Bulk Oxygen Systems at Consumer Sites: 2-2.10
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1. Based on observations, record (i.e., panel board schedule) reviews, and staff interviews during the survey, the Tisch Building was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99. For example, the facility did not ensure that Emergency System-Life Safety Branch wiring was separated from Emergency System-Critical Branch wiring. This deficiency was noted in both existing and newly renovated/constructed areas of this facility.

Findings include, but are not limited to, the following:

a) On 02/18/14 at 10:45AM, wiring from emergency power system panel "EM-RP-G692-TH-18S" that serves newly installed elevators in the Tisch Building was found to serve both Emergency System - Life Safety Branch loads (e.g., Elevator cab lights) and Equipment System loads (i.e., elevator air conditioners and heater units). As per concurrent interview with the facility's Director of Engineering, he will notify Administration concerning this condition.

b) On the morning of 02/18/14, wiring from emergency power system panel "E17-2" on the 17th Floor in the Tisch Building was found to serve both Equipment System loads (e.g., Honeywell {HVAC} system control panel, compressor) and Emergency System - Critical Branch loads (i.e., Nurse call system, bedside receptacles).

c) On the afternoon of 02/18/14, wiring from emergency power system panel "ECRL-ICU-15W Section III" on the 15th Floor West Intensive Care Unit in the Tisch Building was found to serve both Equipment System loads (e.g., fire/smoke dampers) and Emergency System - Critical Branch loads (i.e., electric bedpan hopper, headwall physiological monitors, bedside receptacles).

d) On the afternoon of 02/18/14, wiring from emergency power system panel "ELS-15E/W" on the 15th Floor East Unit in the Tisch Building was found to serve both Emergency System - Life Safety Branch loads (e.g., exit signs, corridor lighting, medical gas alarm panels) and Emergency System - Critical Branch loads (i.e., automatic water faucets, patient room clock, Pharmacy fan).

e) On the afternoon of 02/18/14, wiring from emergency power system panel "EMRP-G1-12-TH-14W-1A" on the 14th Liver/Kidney Transplant Unit in the Tisch Building was found to serve both Emergency System - Life Safety Branch loads (e.g., corridor lighting, medical gas alarm panels) and Emergency System - Critical Branch loads (i.e., corridor and room receptacles, refrigerator).

f) On the afternoon of 02/18/14, wiring from emergency power system panel "EMPP-G1-12 TH-13W1" (also known as Panel "E13-1") on 13th Floor Obstetrical/Postpartum Unit of the Tisch Building was found to serve both Emergency System - Life Safety Branch loads (e.g., corridor lighting, medical gas alarm panels) and Emergency System - Critical Branch loads (i.e., Nursery receptacles, refrigerator, patient room receptacles). It was also noted that emergency power panel "EDPCR-13E" served both Emergency System - Life Safety Branch loads (e.g., medical gas alarm panels) and Emergency System - Critical Branch loads (i.e., room receptacles, Nurse call system).

g) On the afternoon of 02/18/14, wiring from emergency power system panel "ECRL-SD-12E" on 12th Floor of the Tisch Building was found to serve both Emergency System - Life Safety Branch loads (e.g., medical gas alarm panels) and Emergency System - Critical Branch loads (i.e., task lighting, patient room receptacles, refrigerator).

h) On the afternoon of 02/18/14, wiring from emergency power system panel "E9-6" on the 9th Floor of the Tisch Building was found to serve both Emergency System - Life Safety Branch loads (e.g., passenger elevator lighting) and Emergency System - Critical Branch loads (i.e., Nurse call system, patient room receptacles).

i) On the morning of 02/19/14, wiring from emergency power system panel "ERP-A" on the 10th Floor Ambulatory Surgery Unit of the Tisch Building was found to serve both Emergency System - Life Safety Branch loads (e.g., medical gas alarm panel) and Emergency System - Critical Branch loads (i.e., flash sterilizers, endoscope washer, OR blanket warmer, OR scrub sinks, corridor receptacles).

j) On the morning of 02/19/14, wiring from emergency power system panel "ERP-A" on the 8th Floor Obstetrics Unit of the Tisch Building was found to serve both Emergency System - Life Safety Branch loads (e.g., medical gas alarm panel, corridor lighting) and Emergency System - Critical Branch loads (i.e., room receptacles, exam lights).

k) On the morning of 02/19/14, wiring from emergency power system panel "ERP-A" on the 5th Floor Cardiac Catheterization Unit of the Tisch Building was found to serve both Emergency System - Life Safety Branch loads (e.g., medical gas alarm panel, exit lights) and Emergency System - Critical Branch loads (i.e., room receptacles, monitors).

l) On the morning on 02/19/14, wiring from emergency power system panel "EMCRRP-G6-42-TH-4MIL-1" on the recently renovated (May, 2013) 4th Floor Same Day Admitting of the Tisch Building was found to serve both Emergency System - Life Safety Branch loads (e.g., medical gas alarm panel) and Emergency System - Critical Branch loads (i.e., room receptacles).

m) On the afternoon of 03/03/14, reviews of NFPA 76, Essential Electrical Systems for Hospitals, 1967 Edition, NFPA 76A, Essential Electrical Systems for Health Care Facilities, 1973 Edition, NFPA 70, National Electrical Code, 1965 Edition, NFPA 70, National Electrical Code, 1968 Edition, and NFPA 70, National Electrical Code, 1971 Edition, revealed that wiring from the emergency power system was required to be separated from normal power wiring as far back as 1965.

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


2. Based on observations, record (i.e., panel board schedule) reviews, and staff interviews during the survey, the Schwartz Health Care Center Building was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99. For example, the facility did not ensure that Emergency System - Life Safety Branch wiring was separated from Emergency System - Critical Branch wiring. In addition, the facility was unable to identify if all required equipment that required emergency power were provided with an emergency power source. This deficiency was noted in both existing and newly renovated/constructed areas of this hospital.

Findings include, but are not limited to, the following:

a) On the morning of 02/20/14, wiring from emergency power system panel "LSLP-G4-69-HCC-14W-1" (also identified as "ELP-14") on the 14th Floor in the Schwartz Health Care Center Building was found to serve both Equipment System loads (e.g., air conditioner condensation pump, fire/smoke dampers) and Emergency System - Life Safety loads (i.e., corridor lighting).

b) On 02/20/14 at 10:52AM, the specific electrical panel or panels that provide power for the medical gas alarm system alarm panels on the 12th and 13th Floors of the Schwartz Health Care Center Building could not be identified. As per concurrent interview with the facility's Director of Engineering, he will have his staff attempt to identify the electrical panels that serve these alarm panels.

c) On the morning of 02/20/14, wiring from emergency power system panel "LSRP-G4-69-HCC-12W-1" (also identified as "ELP-12") on the 12th Floor in the Schwartz Health Care Center Building was found to serve both Emergency System loads (e.g., room receptacles) and Emergency System - Life Safety loads (i.e., corridor lighting).

d) On the morning of 02/20/14, wiring from emergency power system panel EMRP-G4-62-HCC-10W-1 "(also identified as "ERP-10") on the 10th Floor in the Schwartz Health Care Center Building was found to serve both Emergency System loads (e.g., room receptacles, T.V. receptacles, refrigerators) and Emergency System - Life Safety loads (i.e., corridor lighting, exit lights).

e) On the afternoon of 03/03/14, reviews of NFPA 76, Essential Electrical Systems for Hospitals, 1967 Edition, NFPA 76A, Essential Electrical Systems for Health Care Facilities, 1973 Edition, NFPA 70, National Electrical Code, 1965 Edition, NFPA 70, National Electrical Code, 1968 Edition, and NFPA 70, National Electrical Code, 1971 Edition, revealed that wiring from the emergency power system was required to be separated from normal power wiring as far back as 1965.

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
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1. Based on observations and staff interview during the survey, the facility failed to ensure that all interior ceiling finishes in rooms in existing Assembly Occupancies are of a Class A, Class B, or Class C Interior Wall and Ceiling Finish that were tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials.

Findings:

On 02/21/14 at 8:55AM, a wooden ceiling assembly was noted to have been installed in a 13th Floor non-sprinkler protected Existing Assembly Occupancy (i.e., Cafeteria Area) in the Hospital for Joint Diseases Building. As per concurrent interview with the facility's Assistant Director of Engineering, he did not know the rating of this interior finish but would attempt to find out.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 13.3.3.2


2. Based on observations and interview, the facility failed to ensure that all sleeping rooms (i.e., Lodging and Rooming House Occupancies) that would require a smoke detector were provided with one.

Findings:

On 02/21/14 at 11:40AM, an On-Call Physician Sleeping Room located on the newly renovated 8th Floor of the Hospital for Joint Diseases Building (e.g. Room HJ-863) was found to lack a required smoke detector in the room. As per concurrent interview with the facility's Assistant Director of Engineering, he will inform his Supervisor of this issue.

42CFR 482.41(b), NFPA 101-2000: 19.1.2, 6.1.14, 26.3.3.5


3. Based on observations and staff interview during the survey, the facility failed to ensure that the Fire Pump Room was provided with required battery-powered emergency lights.

Findings:

On 02/21/14 at 3:35PM, the room containing the facility's fire pump (Room C27) was found to lack required battery-powered emergency lights on Floor CB of the Hospital for Joint Diseases Building. NFPA 20-1999, Standard for the Installation of Stationary Pumps for Fire Protection Section 2-7.4 requires that in fire pump rooms that: "Emergency lighting shall be provided by fixed or portable battery-operated lights, including flashlights. Emergency lights shall not be connected to an engine-starting battery". As per concurrent interview with the facility's Assistant Director of Engineering this fire pump had been installed in 2008 and that battery-powered emergency lighting would be installed in the Fire Pump Room as soon as possible.

42 CFR 482.41(b), NFPA 13-1999, Standard for the Installation of Sprinkler Systems: 9-2.2, NFPA 20-1999, Standard for the Installation of Stationary Pumps for Fire Protection: 2-7.4
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1. Based on observations and staff interview during the survey, 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 shall be effectively closed to afford protection substantially equivalent to the wall of the equipment were provided in accordance with the requirements of NFPA 70, National Electrical Code.

Findings include, but are not limited to, the following:

a) On the morning of 02/21/14, two (2) unprotected openings caused by missing circuit breakers (#16 and #18) were noted in emergency electrical panel "ELP-12L" on the 12th Floor of the Hospital for Joint Diseases Building.

b) On the morning of 02/21/14, an electrical junction box located above the suspended ceiling in the 9th Floor Staff Lounge (vicinity of Equipment Storage Room HJ913B) in the Hospital for Joint Diseases Building was noted to lack a cover plate on one (1) side of the box.

c) On 02/21/14 at 2:09PM, an unprotected opening caused by missing circuit breaker (#26) was noted in normal electrical panel "LPL-3B" on the 3rd Floor of the Hospital for Joint Diseases Building. As per concurrent interview with the facility Assistant Director of Engineering, he will inform his Supervisor of this issue.

d) On 02/24/14 at 8:20AM, five (5) unprotected openings caused by missing circuit breakers (#1, #7, #8, #13, #14) were noted in emergency power system panel "ELPL-2SLA" and two (2) unprotected openings caused by missing circuit breakers (#16 and #30) were noted in emergency power system panel "ELPL-25CA Sec 2" in an Operating Room Unit Equipment Storage Room on Floor SC2 in the Hospital for Joint Diseases Building.

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


2. Based on observations and staff interview during the survey, the facility failed to ensure that all panel board circuits and circuit modifications shall be 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 NFPA 70, National Electrical Code.

Findings include, but are not limited to, the following:

a) On the morning of 02/21/14 the following examples in the newly renovated Hospital for Joint Diseases Building 9th Floor South Unit were noted:

-The Circuit Directory that was located inside normal power electrical panel "LPL-9C Section 1" indicated that circuits #15, #17, #8, #10, #12, #22 and #28 served "Existing Loads" but failed to identify the specific purpose that these circuits served.

-The Circuit Directory that was located inside emergency power electrical panel "ELPL-9C Section 2" indicated that circuits #1, #4, #6, #8, #10, #12, #15, #18 and #20 served "Existing Loads" but failed to identify the specific purpose that these circuits served.

-The Circuit Directory that was located inside emergency power electrical panel "ELPE-9E" indicated that circuits #1, #3, #5, #7, #9, #10, #11, #12, #13, #14, #15 and #16 served "Existing Loads" but failed to identify the specific purpose that these circuits served.

-The Circuit Directory that was located inside emergency power electrical panel "ELPE-9L" indicated that circuits #1, #2, #3, #4, #5, #6, #7 and #8 served "Existing Loads" but failed to identify the specific purpose that these circuits served.

b) On 02/21/14 at 2:15PM, emergency power panels "ELPL-3E", "ELPL-3C Section #1" and "ELPL-3C Section #2" in a 3rd Floor Electrical Room (vicinity of the 3 North Elevator Lobby) in the Hospital for Joint Diseases Building lacked Circuit Directories.

c) On 02/24/14 at 8:20AM, an emergency power system that lacked an identification (i.e., panel name) located in the vicinity of Operating Room #9 on Floor SC2 in the Hospital for Joint Diseases Building lacked a lacked a Circuit Directory.

d) On 02/24/14 at 8:25AM, an emergency power system panel "ELPL-25CA Sec 2" in an Operating Room Unit Equipment Storage Room on Floor SC2 in the Hospital for Joint Diseases Building lacked a lacked a Circuit Directory.

Failure to identify circuit functions could impede facility staff and/or emergency responders trying to determine the source of problems with an electrical system.

As per interview with the facility's Assistant Director of Engineering on 02/21/14 at 10:44AM, he will notify Administration concerning this condition.

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


3. Based on observations and staff interviews, the facility failed to ensure that all temporary wiring had been removed upon completion of construction.

Findings:

a) On the morning of 02/21/14, temporary wiring was found above the suspended ceiling in the 9th Floor Staff Lounge (vicinity of Equipment Storage Room HJ913B) in the Hospital for Joint Diseases Building.

b) On 02/21/14 at 11:40AM, temporary wiring was found above the suspended ceiling in an On-Call Physician Sleeping Room located on the newly renovated 8th Floor of the Hospital for Joint Diseases Building (e.g. Room HJ-863). As per concurrent interview with the facility's Assistant Director of Engineering, he will have the temporary wiring removed a soon as possible.

c) On 02/21/14 at 1:45PM, temporary wiring was found above the suspended ceiling in Staff Toilet Room HJ442B on the 4th Floor of the Hospital for Joint Diseases Building.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 305-3 (d)