HospitalInspections.org

Based on observations during the Life Safety Code survey, it was noted that structural components of the facility were not properly protected from fire. Issues include structural steel /steel beams of the building and the beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type II (222).

The findings are:

During the survey from 01/07/14 to 01/13/14 between 11:00 AM to 4:00 PM, observations were made above the suspended ceilings in the facility, in the mechanical areas and other areas where the structural beam was visible from the floor level. During the observation it was revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above in many places were not completely protected with a fire resistive material.

Few examples of some unprotected I-beams including but not limited to are:
i. Structural beam above the double door entrance to the Central Sterile Workroom-Mural Pavilion.
ii. Various areas on the structural beam in the basement of mechanical room ( housing the main switch gear)-Mural Pavilion.

Findings were verified with Director of Facilities and Engineering Staff accompanying the surveyor during the survey.

2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1
.

Based on document review and staff interview, the facility did not ensure that the fire drills were conducted under varying conditions and that planning / evaluation of fire drills were done as per NFPA 101.

Findings include:

1. A review of the fire drill record on 01/09/14 at 4:00 PM indicated that the facility has instituted a checklist highlighting the points of the drill on which the staff conducting the drill/observer checks off "yes" or "no".

Review of fire drill records indicated that the hospital did not conduct fire drills that include 'simulation of various types of emergency fire conditions' to ensure that each staff has a full and clear understanding of the facility's fire safety plan and how to execute it successfully under the varying conditions.

The fire drills checklist or report did not indicate under what scenario the fire drill was initiated.

2. The facility's fire drill records included staff sign-in sheets, the facility failed to document in the records, a critique of the drill, the staff's fire drill response, and the staff knowledge of evacuation procedure to ensure that the staff was fully aware of fire drill/evacuation protocols.

Findings were verified with the Chief Operating Officer, Director of Emergency Preparedness and the personnel responsible for conducting fire drills.

Based on document review and staff interview, it was determined that (a) the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1, and (b) the facility did not ensure that all sprinkler pipes are free of any foreign material and paints as per NFPA 25 and NFPA 13, Standard for the Inspection, Testing and Maintenance of Water Based Fire and Protection System.

Findings include:

A1. On 01/09/14 at 12:00 PM, during documentation review for the sprinkler test, it was noted and verified by Director of Engineering that there are no documentation or report available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves were conducted. Furthermore, no verification was presented to verify if the gauges were recalibrated or replaced in the past five years.

Note: As per NFPA, there are two activities that are related to obstructions in Chapter 13 that require attention. The first is an investigation that is actually more of an "inspection" as described in Section 13.2.1 that must be conducted every five years. While the sprinkler system is shut down for the purpose of internal valve inspections (See Table 12.1), the flushing connection at the end of one cross main and a single sprinkler at the end of one branch line must be removed and the inside of the piping is then "inspected" for the presence of organic and inorganic material. In Section 13.2.2 a more comprehensive obstruction "investigation" must be conducted when any of the 14 conditions listed in that section are present. This more comprehensive obstruction "investigation" is conducted by internally examining the following four points in a system: system valve, riser, crossmain and, branchline.

THIS IS A REPEAT CITATION FROM THE FULL FEDERAL SURVEY OF THE FACILITY DATE 2010. The facility was cited for the same issue and had responded in its plan of correction 'The facility has reviewed all the requirements in NFPA 25 for the inspection, testing and maintenance of water based fire protection systems. The facilities Management Department has modified their desisting monthly/quarterly/semi-annual/annual preventive maintenance programs for water based protection systems to include all of the appropriate elements of NFPA 25. This includes the preventive maintenance of the sprinkler water storage tank, the O S and Y valves and five year inspection and testing for the sprinkler piping alarm valves and associated trim'.

No such information was present at the time of survey for 5 year inspection.

A2. On 01/09/14 at 12:30 PM document and reports for five year 'Standpipe Hydrostatic test and Flow Test' were requested and reviewed. Facility provided a document from Fire Department of New York ( FDNY)] dated 12/02/1008 for MLK building indicating that 'A test conducted by Stellmar Plumbing on the Standpipe/4 Siamese Connection system was witnessed to be Satisfactory in accordance with the regulations of this Department' . This document did not state what 'test' was conducted.

No other document was provided for the 5 year hydrostatic test for MLK building or the other sprinklered buildings of the facility indicating the test's compliance with code NFPA 25 1999 section 3-3.2.1 which states:
'Hydrostatic tests at not less than 200-psi (13.8-bar) pressure for 2 hours, or at 50 psi (3.4 bar) in excess of the maximum pressure, where maximum pressure is in excess of 150 psi (10.3 bar), shall be conducted every 5 years on dry standpipe systems and dry portions of wet standpipe systems'.

Director of Facilities stated that this test is conducted in presence of FDNY and witnessed by them therefore it is sufficient. It is to be noted that the document clearly states that the 'test' is in accordance with the Department's/FDNY regulation and does not state that the test is in lieu/alternative/equivalent/acceptable or in compliance as per NFPA 25.


A3. On 01/09/14 at 12:45 PM, during review of the main drain test report for the sprinkler systems it was noted that all the reports did not have the comparison of the static and residual pressure from the last year's report. Furthermore, for Ron Brown Building the differences between the static and residual values were more than 25 PSI and it could not be determined if this pressure difference is normal for the sprinkler system and is as per its hydraulic plate information or it does not meet the hydraulic plate requirement.


B1. During the tour of the facility from 01/07/14 to 01/13/14 between 11:00 AM to 3:30 PM, it was observed that the exposed sprinkler heads in various parts of the facility exhibited accumulation of dust, and paint specks.

Examples including but not limited to are:

i- Sprinkler head by the double door of the old EMT entrance on the 1st floor MLK had dust and speck of paint.
ii- Sprinkler head in the soiled linen room of the Psychiatric 10th floor MLK was noted having dust ball hanging by a thread.

Note: Section 2-2.1.1* of NFPA 25 states that, "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

All above findings were verified with the Director of Facilities, Director of Engineering and Chief Operating Officer.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10). Additionally, the facility did not ensure that the fire extinguishers are stored in such a manner that they are easily accessible.

Findings include:

1. During survey of facility from 01/07/14 to 01/13/14 between 10:30 AM to 3:45 PM, it was noted that in various floors of the different buildings of the facility, the fire extinguishers were installed on the wall or in the recess cabinet is such a way that its topmost portion was greater than the required 5 ft. (60 inches).

Examples including but not limited to are:

i. Near the Trauma room in the Emergency Department the fire extinguisher in the recess cabinet was 62 inches above the floor. Another extinguisher near the exam/treatment rooms of the emergency department was also noted 63 inches above the floor.

ii. In Kountz Pavilion the fire extinguisher outside the mechanical room in the basement was noted installed at a height greater than 60 inches.
2. During survey of the facility, it was noted that some of the fire extinguishers were blocked by equipment/carts thus making the portable extinguishers not readily accessible at the time of emergency.

Examples including but not limited to:

i. On 01/06/14 at 11:30 AM, the fire extinguisher in the trauma room -Emergency Department was noted blocked by equipment.
ii. On 01/13/14 at 3:30 PM , in KP building, fire extinguisher in the mechanical room was noted blocked by a cart.

Note: Section 1-6.3 of NFPA 10 states that fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

All findings for extinguishers issue were observed and verified with, Director of Facilities and Chief Operating Officer.

Based on documentation review and staff interview, the facility failed to ensure that all fire dampers installed in all buildings at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair and installed in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

1. On 01/09/14 at 11:00 AM, during review of fire/smoke damper assessment of MLK and Mural Pavilion dated from 07/13 to 10/13, it was noted that many dampers had deficiencies in the building. No corrective action follow up report was provided.

The Director of Facilities provided a work order from Johnson Controls that states that the target to start the work was 12/17/13 and finish was 01/09/14. However no work has started on the project as per Director of Facilities.

Furthermore, this work order in its heading states that 'This work order does not constitute an authorization to commence work; The Service Provider can only commence work upon a valid purchase order from JCI was provided to verify that those deficiencies were corrected'. No other follow up was provided.

The Director of Engineering stated that sometimes due to patients occupying an area or other reasons, the damper cannot be accessed, and therefore it is either not tested or cannot be accessed again after a deficiency is found. No documentation/policy was provided regarding what the facility intends to do in the interim to provide patient safety and how do they assess it.

2. During the inspection of the fire and smoke barriers in the facility from 01/07/14 to 01/13/14 between 11:30 AM to 4:00 PM, it was noted that that there were various ducts penetrating through the fire/smoke barrier. These ducts had fire sealant/caulking around it. The ducts were equipped with fire dampers.
NOTE: As per NFPA 90A 3-4.6 Exception: Where fire dampers are installed, proper clearance for expansion shall be maintained. (See 3-4.6.)

Therefore as per the above section, the code requires proper clearance for expansion should be maintained.
Furthermore NFPA 90A section 3-4.6.2* states that "Fire dampers, including their sleeves; smoke dampers; and ceiling dampers shall be installed in accordance with the conditions of their listings and the manufacturer 's installation instructions".

The UL Building Material Directory also does not allow the space to be filled with any material.

Examples of fire retardant material around the ducts including but not limited to are:
i- The duct passing the fire/smoke barrier above the double door near the old EMT entrance -MLK building 1st floor.
ii- The duct passing the fire/smoke barrier above the double door by the entrance of the Psychiatric Unit 10th floor -MLK building.

Thus facility did not ensure that the ducts with fire dampers do not have their angles sealed with fire caulking or sealant as that compromises the fire damper UL listing as per UL 555.

Findings were verified with the Director of Engineering at the time of document review and Director of Facilities, Engineering Personnel and Chief Operating Officer at the time of observation.

Based on observation and staff interview, the facility failed to ensure that the artificial decorative plants displayed in the facility are not constructed of combustible material, unless otherwise rendered flame retardant.

The findings include:

During the survey of Ron Brown building on 01/13/14 between 11:00 AM to 1:00 PM, it was observed that the facility has many decorative artificial plants (potted in ceramic/tiled built-in 5-6 feet or more long planters) in the main lobby/waiting room of the various floors.

An interview with Director of Facilities at the time of observations revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. He stated that he he will try to look for the specifications, however no information was provided.


Findings were verified with Director of Facilities and Chief Operating Officer.

Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6 . Furthermore, the fire/smoke barriers were not maintained for its full integrity.

Findings include:

During the tour of the facilities between 01/07/14 to 01/13/14 between 11:00 AM to
4:00 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected for the integrity of smoke barriers. The rated walls of different areas were also inspected for integrity.

It was noted that the fire/smoke barriers that were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes did not have complete seal all around to prevent passage of smoke from one compartment to the other or the devices used to prevent migration of smoke was not properly maintained.

Examples, including but not limited to include:

a. The HILTI sleeves in the fire/smoke barrier through which many cables were passing from one side of the barrier to the other, were noted not closed to seal and prevent passage of smoke. An example was in the fire/smoke barrier wall by entrance of Central Sterile Processing Area-MP building-4 th floor

b. Gaps/holes were noted in the 2 hour fire wall above the double door in the old EMT entrance area-MLK-1st floor.

These findings were verified with the Director of Facilities and Chief Operating Officer

Note: Section 8.3.6.1 of NFPA 101 states that:

Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

b. It shall be protected by an approved device that is designed for the specific purpose.

Based on staff interview and document review, the facility failed to maintain the emergency generators in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4 and NFPA 110 thus allowing it to transfer in 10 seconds.

Findings include.

On 01/09/14 at 2:00 PM, during documentation review of the emergency generator monthly load test logs, it was noted that there was no transfer time for the transfer switches on emergency generators.

To meet state and Federal licensure requirements, healthcare facilities must exercise their emergency generators under load at least monthly, and time delays must be set as follows:
a. Time delay on start: 1 second minimum.*
Exception: Gas turbine cycle: 0.5 second minimum.
*Note: NFPA 101(00), Sec. 7.9.1.2 requires that emergency loads be picked up within 10 seconds.
Based on the review of facility's logs it could not be revealed if the generators meet the above guidelines since there was no transfer time or load pick up time indicated in the logs.
Note: It is important to verify that the emergency generator is capable of transferring the load as per the following requirements of every monthly load test:

NFPA 99 1999 - 3-4.3 Performance Criteria and Testing (Type 1 EES).
3-4.3.1 Source.
The branches of the emergency system shall be installed and connected to the alternate power source specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.

NFPA 99 1999- 3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1].

Findings were verified with Director of Facilities.

A. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13 1999 [Standard for the Installation of Sprinkler Systems], to provide complete coverage in the fully sprinklered Mural Pavilion.

Findings include:

During the tour of the Mural Pavilion on 01/07/14 at 3:00 PM, it was noted that the elevator machine room in the 4 th floor did not have any sprinkler head. Mural Pavilion is a fully sprinklered building and therefore as per NFPA 13 requires a sprinkler head in elevator machine room.

Findings were observed and verified with Director of and Director of Environmental and Health Services.

B. Based on observation, it was determined that the facility failed to provide a battery back up light for the generator of Kountz pavilion.

Findings include:

On 01/13/14 AT 4;00 PM , it was noted that the generator room/trailer, housing the generator for KP building, did not have an emergency battery powered back up light.

Note: Subsection 5-3.1 of NFPA 110 requires that:
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

C. Based on observation, facility did not ensure that the stairwell exit signs have all required information as per NFPA 101 7.2.2..5.4 and that they are installed in such a manner that they are readily visible in the open and closed position of the doors.

Findings include:

During the survey of Mural Pavilion on 01/07/14 at 12:15 PM, it was noted that the stairwell sign in the staircase did not have the information for roof access. An example of such was noted in Stair Well 'A' on the 3rd floor.

Note:
7.2.2.5.4* Stair Identification Signs.
Stairs serving five or more stories shall be provided with signage within the enclosure at each floor landing. The signage shall indicate the story, the terminus of the top and bottom of the stair enclosure, and the identification of the stair enclosure. The signage also shall state the story of, and the direction to, exit discharge. The signage shall be inside the enclosure located approximately 5 ft (1.5 m) above the floor landing in a position that is readily visible when the door is in the open or closed position.

Furthermore, on 01/13/14 at 2:45 PM, similar issue was noted in Women's pavilion. The signs in WP building only had identification of the stair well and not all other information as required by the code.

It was also noted during the facility's tour of all buildings that the stairwell signs were not always installed in a manner that vital egress information is seen by the occupants of a building and by fire fighters in case of emergency.

All above findings were verified with Chief Operating Officer and Director of Facilities along with engineering personal.

Based on document review and staff interview, it was determined that the facility performs general anesthesia and has emergency generators installed in the facility and thus requires a Type I EES (essential electrical system). The wiring of the electrical system at the panels on patient care floors in the Martin Luther King Pavilion are not in compliance with the code, NFPA 99 3-4, and generators are not divided into three branches.

Findings include:

1. On 01/09/14 in an interview with Director of Facilities at 1:30 PM, the Director of Facilities and Director of Engineering indicated that the wiring configuration in the MLK building for the Type I EES is not in compliance with 1999 NFPA 99 3-4.2.2.1.

The specific issue involved was that the separation of the generator branches into a life safety, critical, and equipment system was not done for the generators and panels on patient floors were not provided for segregating the three branches. Thus the panels at the main mechanical room/switch gear room/generator has mixed wiring for life safety, critical, and equipment branches in whatever panel is present in the facility and the wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System, and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch.

1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.


THIS IS A REPEAT CITATION FROM THE FULL FEDERAL SURVEY OF 2010.

The Facility was cited for this same issue and facility had responded that 'In accordance with new LSC standards for electrical distribution, as specified by NFPA 99 and NFPA 70, the existing TYPE 1 EES will be modified. The physical plant modernization project will ensure that all components in the plan are in accordance with NFPA 99. Facilities Management and Modernization Department will ensure that all components are incorporated into the plan according to NFPA 99 standards. The estimated completion date for the project is 2/2012'.

As per Director of Facilities. the facility started doing the project, managed to separate 6 out of 10 transfer switches ( those new 6 are dedicated to elevator) however the rest 4 still have mixed wiring. As per the Director of Facilities the reason why the project could not be completed in a timely manner was lack of resources/funds.

No information prior to the survey was ever provided to DOH or CMS regarding the facility's intention of extending the project due to circumstances and not completing as promised and indicated by their response in 2010.

A. Based on staff interview all electrical receptacles in patient care areas were not tested and maintained as per code.

Findings include:

On 01/13/14 at 3:00 PM, the Director of Facilities was requested to provide evidence that electrical receptacles in the patient care areas were tested. Director of Facilities and Director of Engineering stated stated there were no such records. The facility also did not have any policy and procedure in place regarding how often should it be conducted.

NOTE:
As per NFPA 1999 (99 ed) section 3-3.4.2.3 Maintenance and Testing of Electrical system Testing Interval for Receptacles in Patient Care Areas.

(1) Testing shall be performed after initial installation, replacement, or servicing of the device.

(2) Additional Testing shall be performed at intervals defined by documented performance data.

The codes of NFPA 99 1999 3-3.3.3 and 3-3.3.3.2 identify the most pertinent tests required to be verified.

Facility needs to ensure full compliance with NFPA 99 Chapter 3 and NFPA 70.

Facility needs to determine the frequency of testing by evidence based data and ensure that servicing of the electrical receptacles is done as per NFPA 99 so that all receptacles are operational with no electrical leakage or any other problem.

B. Based on observation, facility did not ensure that all in-patient bed locations have electrical receptacles getting its power from normal and emergency or have dedicated emergency power receptacles.

Findings included:

On 01/10/14 between 2;00 PM to 4:00 PM, during the tour of the Pediatric floor-MLK-17th floor and Maternity Floor -MLK-4th floor, it was noted that the receptacles by the bed side did not have any red outlets/emergency power outlets. There was no other indication or labeling that there are other receptacles apart from normal power that may assist in patient care in case of power outage

NOTE: NFPA 70
517-18. General Care Areas
(a) Patient Bed Location. Each patient bed location shall be supplied by at least two branch circuits, one from the emergency system and one from the normal system. All branch circuits from the normal system shall originate in the same panelboard.
Exception No. 1: Branch circuits serving only special-purpose outlets or receptacles, such as portable X-ray outlets, shall not be required to be served from the same distribution panel or panels.
Exception No. 2: Requirements of Section 517-18(a) shall not apply to patient bed locations in clinics, medical and dental offices, and outpatient facilities; psychiatric, substance abuse, and rehabilitation hospitals; sleeping rooms of nursing homes and limited care facilities meeting the requirements of Section 517-10(b)(2).
Exception No. 3: A general care patient bed location served from two separate transfer switches on the emergency system shall not be required to have circuits from the normal system.

C- Based on document review and staff interview, facility did not ensure that the electrical safety test was conducted on the patient care instruments as per frequency defined by NFPA 99.

Findings include:

On 01/09/14, facility was requested to provide electrical safety test for all equipments in the facility. The Director of Bio-med provided a policy and procedure titled ''Policy on Maintaining. Testing & Inspecting Med Equipment'. This policy did not include the frequency of electrical testing and was more geared towards the preventive maintenance of the equipment.

Furthermore, on 01/13/14 two equipment 'Pentamix' with serial number 978003002332 and M575106 were noted in the Dental Out-patient clinic and it was written on their preventive maintenance sticker that no re-inspection needed.

When the last preventive maintenance record was requested. it was found that they had their last electrical safety check on 07/12/03 (10 years back).

As per NFPA 99 section 7-6.2.1.2 Testing Intervals.
(a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance.
(b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:
General care areas - 12 months
Critical care areas - 6 months
Wet locations - 6 months
Exception No. 1: The testing intervals listed are intended to be nominal values, and facilities shall be permitted to adopt a protocol using either longer or shorter intervals provided that there is a documented justification based on previous safety testing records for the equipment in question, unusually light or heavy utilization, or similar considerations.
Exception No. 2: Facility-owned household or other appliances that are used in the patient care vicinity, but that are not intended to contact the patient, shall be tested at intervals deemed appropriate by the facility. Some equipment in this category requires only an infrequent visual inspection. The facility shall be permitted to structure a testing protocol and frequency for some equipment that might be more limited than that prescribed in 7-5.1.3.
Exception No. 3: The tests specified in 7-5.1.3.6, Lead Leakage Current Tests and Limits, Portable Equipment, shall be required only for incoming inspections and following repairs and modifications that might have compromised the patient lead leakage current.
Exception No. 4: * After the installation of fixed equipment, it shall be tested periodically in accordance with 3-3.3.2.3, and meet the following criteria:
(a) 500 mV for general care areas
(b) 40 mV for critical care areas

Facility did not comply with the above requirement.

Findings were verified with Director of Facilities and Chief Operating Officer.

Based on observations during the Life Safety Code survey, it was noted that structural components of the facility were not properly protected from fire. Issues include structural steel /steel beams of the building and the beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type II (222).

The findings are:

During the survey from 01/07/14 to 01/13/14 between 11:00 AM to 4:00 PM, observations were made above the suspended ceilings in the facility, in the mechanical areas and other areas where the structural beam was visible from the floor level. During the observation it was revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above in many places were not completely protected with a fire resistive material.

Few examples of some unprotected I-beams including but not limited to are:
i. Structural beam above the double door entrance to the Central Sterile Workroom-Mural Pavilion.
ii. Various areas on the structural beam in the basement of mechanical room ( housing the main switch gear)-Mural Pavilion.

Findings were verified with Director of Facilities and Engineering Staff accompanying the surveyor during the survey.

2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1
.

Based on document review and staff interview, the facility did not ensure that the fire drills were conducted under varying conditions and that planning / evaluation of fire drills were done as per NFPA 101.

Findings include:

1. A review of the fire drill record on 01/09/14 at 4:00 PM indicated that the facility has instituted a checklist highlighting the points of the drill on which the staff conducting the drill/observer checks off "yes" or "no".

Review of fire drill records indicated that the hospital did not conduct fire drills that include 'simulation of various types of emergency fire conditions' to ensure that each staff has a full and clear understanding of the facility's fire safety plan and how to execute it successfully under the varying conditions.

The fire drills checklist or report did not indicate under what scenario the fire drill was initiated.

2. The facility's fire drill records included staff sign-in sheets, the facility failed to document in the records, a critique of the drill, the staff's fire drill response, and the staff knowledge of evacuation procedure to ensure that the staff was fully aware of fire drill/evacuation protocols.

Findings were verified with the Chief Operating Officer, Director of Emergency Preparedness and the personnel responsible for conducting fire drills.

Based on document review and staff interview, it was determined that (a) the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1, and (b) the facility did not ensure that all sprinkler pipes are free of any foreign material and paints as per NFPA 25 and NFPA 13, Standard for the Inspection, Testing and Maintenance of Water Based Fire and Protection System.

Findings include:

A1. On 01/09/14 at 12:00 PM, during documentation review for the sprinkler test, it was noted and verified by Director of Engineering that there are no documentation or report available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves were conducted. Furthermore, no verification was presented to verify if the gauges were recalibrated or replaced in the past five years.

Note: As per NFPA, there are two activities that are related to obstructions in Chapter 13 that require attention. The first is an investigation that is actually more of an "inspection" as described in Section 13.2.1 that must be conducted every five years. While the sprinkler system is shut down for the purpose of internal valve inspections (See Table 12.1), the flushing connection at the end of one cross main and a single sprinkler at the end of one branch line must be removed and the inside of the piping is then "inspected" for the presence of organic and inorganic material. In Section 13.2.2 a more comprehensive obstruction "investigation" must be conducted when any of the 14 conditions listed in that section are present. This more comprehensive obstruction "investigation" is conducted by internally examining the following four points in a system: system valve, riser, crossmain and, branchline.

THIS IS A REPEAT CITATION FROM THE FULL FEDERAL SURVEY OF THE FACILITY DATE 2010. The facility was cited for the same issue and had responded in its plan of correction 'The facility has reviewed all the requirements in NFPA 25 for the inspection, testing and maintenance of water based fire protection systems. The facilities Management Department has modified their desisting monthly/quarterly/semi-annual/annual preventive maintenance programs for water based protection systems to include all of the appropriate elements of NFPA 25. This includes the preventive maintenance of the sprinkler water storage tank, the O S and Y valves and five year inspection and testing for the sprinkler piping alarm valves and associated trim'.

No such information was present at the time of survey for 5 year inspection.

A2. On 01/09/14 at 12:30 PM document and reports for five year 'Standpipe Hydrostatic test and Flow Test' were requested and reviewed. Facility provided a document from Fire Department of New York ( FDNY)] dated 12/02/1008 for MLK building indicating that 'A test conducted by Stellmar Plumbing on the Standpipe/4 Siamese Connection system was witnessed to be Satisfactory in accordance with the regulations of this Department' . This document did not state what 'test' was conducted.

No other document was provided for the 5 year hydrostatic test for MLK building or the other sprinklered buildings of the facility indicating the test's compliance with code NFPA 25 1999 section 3-3.2.1 which states:
'Hydrostatic tests at not less than 200-psi (13.8-bar) pressure for 2 hours, or at 50 psi (3.4 bar) in excess of the maximum pressure, where maximum pressure is in excess of 150 psi (10.3 bar), shall be conducted every 5 years on dry standpipe systems and dry portions of wet standpipe systems'.

Director of Facilities stated that this test is conducted in presence of FDNY and witnessed by them therefore it is sufficient. It is to be noted that the document clearly states that the 'test' is in accordance with the Department's/FDNY regulation and does not state that the test is in lieu/alternative/equivalent/acceptable or in compliance as per NFPA 25.


A3. On 01/09/14 at 12:45 PM, during review of the main drain test report for the sprinkler systems it was noted that all the reports did not have the comparison of the static and residual pressure from the last year's report. Furthermore, for Ron Brown Building the differences between the static and residual values were more than 25 PSI and it could not be determined if this pressure difference is normal for the sprinkler system and is as per its hydraulic plate information or it does not meet the hydraulic plate requirement.


B1. During the tour of the facility from 01/07/14 to 01/13/14 between 11:00 AM to 3:30 PM, it was observed that the exposed sprinkler heads in various parts of the facility exhibited accumulation of dust, and paint specks.

Examples including but not limited to are:

i- Sprinkler head by the double door of the old EMT entrance on the 1st floor MLK had dust and speck of paint.
ii- Sprinkler head in the soiled linen room of the Psychiatric 10th floor MLK was noted having dust ball hanging by a thread.

Note: Section 2-2.1.1* of NFPA 25 states that, "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

All above findings were verified with the Director of Facilities, Director of Engineering and Chief Operating Officer.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10). Additionally, the facility did not ensure that the fire extinguishers are stored in such a manner that they are easily accessible.

Findings include:

1. During survey of facility from 01/07/14 to 01/13/14 between 10:30 AM to 3:45 PM, it was noted that in various floors of the different buildings of the facility, the fire extinguishers were installed on the wall or in the recess cabinet is such a way that its topmost portion was greater than the required 5 ft. (60 inches).

Examples including but not limited to are:

i. Near the Trauma room in the Emergency Department the fire extinguisher in the recess cabinet was 62 inches above the floor. Another extinguisher near the exam/treatment rooms of the emergency department was also noted 63 inches above the floor.

ii. In Kountz Pavilion the fire extinguisher outside the mechanical room in the basement was noted installed at a height greater than 60 inches.
2. During survey of the facility, it was noted that some of the fire extinguishers were blocked by equipment/carts thus making the portable extinguishers not readily accessible at the time of emergency.

Examples including but not limited to:

i. On 01/06/14 at 11:30 AM, the fire extinguisher in the trauma room -Emergency Department was noted blocked by equipment.
ii. On 01/13/14 at 3:30 PM , in KP building, fire extinguisher in the mechanical room was noted blocked by a cart.

Note: Section 1-6.3 of NFPA 10 states that fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

All findings for extinguishers issue were observed and verified with, Director of Facilities and Chief Operating Officer.

Based on documentation review and staff interview, the facility failed to ensure that all fire dampers installed in all buildings at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair and installed in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

1. On 01/09/14 at 11:00 AM, during review of fire/smoke damper assessment of MLK and Mural Pavilion dated from 07/13 to 10/13, it was noted that many dampers had deficiencies in the building. No corrective action follow up report was provided.

The Director of Facilities provided a work order from Johnson Controls that states that the target to start the work was 12/17/13 and finish was 01/09/14. However no work has started on the project as per Director of Facilities.

Furthermore, this work order in its heading states that 'This work order does not constitute an authorization to commence work; The Service Provider can only commence work upon a valid purchase order from JCI was provided to verify that those deficiencies were corrected'. No other follow up was provided.

The Director of Engineering stated that sometimes due to patients occupying an area or other reasons, the damper cannot be accessed, and therefore it is either not tested or cannot be accessed again after a deficiency is found. No documentation/policy was provided regarding what the facility intends to do in the interim to provide patient safety and how do they assess it.

2. During the inspection of the fire and smoke barriers in the facility from 01/07/14 to 01/13/14 between 11:30 AM to 4:00 PM, it was noted that that there were various ducts penetrating through the fire/smoke barrier. These ducts had fire sealant/caulking around it. The ducts were equipped with fire dampers.
NOTE: As per NFPA 90A 3-4.6 Exception: Where fire dampers are installed, proper clearance for expansion shall be maintained. (See 3-4.6.)

Therefore as per the above section, the code requires proper clearance for expansion should be maintained.
Furthermore NFPA 90A section 3-4.6.2* states that "Fire dampers, including their sleeves; smoke dampers; and ceiling dampers shall be installed in accordance with the conditions of their listings and the manufacturer 's installation instructions".

The UL Building Material Directory also does not allow the space to be filled with any material.

Examples of fire retardant material around the ducts including but not limited to are:
i- The duct passing the fire/smoke barrier above the double door near the old EMT entrance -MLK building 1st floor.
ii- The duct passing the fire/smoke barrier above the double door by the entrance of the Psychiatric Unit 10th floor -MLK building.

Thus facility did not ensure that the ducts with fire dampers do not have their angles sealed with fire caulking or sealant as that compromises the fire damper UL listing as per UL 555.

Findings were verified with the Director of Engineering at the time of document review and Director of Facilities, Engineering Personnel and Chief Operating Officer at the time of observation.

Based on observation and staff interview, the facility failed to ensure that the artificial decorative plants displayed in the facility are not constructed of combustible material, unless otherwise rendered flame retardant.

The findings include:

During the survey of Ron Brown building on 01/13/14 between 11:00 AM to 1:00 PM, it was observed that the facility has many decorative artificial plants (potted in ceramic/tiled built-in 5-6 feet or more long planters) in the main lobby/waiting room of the various floors.

An interview with Director of Facilities at the time of observations revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. He stated that he he will try to look for the specifications, however no information was provided.


Findings were verified with Director of Facilities and Chief Operating Officer.

Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6 . Furthermore, the fire/smoke barriers were not maintained for its full integrity.

Findings include:

During the tour of the facilities between 01/07/14 to 01/13/14 between 11:00 AM to
4:00 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected for the integrity of smoke barriers. The rated walls of different areas were also inspected for integrity.

It was noted that the fire/smoke barriers that were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes did not have complete seal all around to prevent passage of smoke from one compartment to the other or the devices used to prevent migration of smoke was not properly maintained.

Examples, including but not limited to include:

a. The HILTI sleeves in the fire/smoke barrier through which many cables were passing from one side of the barrier to the other, were noted not closed to seal and prevent passage of smoke. An example was in the fire/smoke barrier wall by entrance of Central Sterile Processing Area-MP building-4 th floor

b. Gaps/holes were noted in the 2 hour fire wall above the double door in the old EMT entrance area-MLK-1st floor.

These findings were verified with the Director of Facilities and Chief Operating Officer

Note: Section 8.3.6.1 of NFPA 101 states that:

Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

b. It shall be protected by an approved device that is designed for the specific purpose.

Based on staff interview and document review, the facility failed to maintain the emergency generators in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4 and NFPA 110 thus allowing it to transfer in 10 seconds.

Findings include.

On 01/09/14 at 2:00 PM, during documentation review of the emergency generator monthly load test logs, it was noted that there was no transfer time for the transfer switches on emergency generators.

To meet state and Federal licensure requirements, healthcare facilities must exercise their emergency generators under load at least monthly, and time delays must be set as follows:
a. Time delay on start: 1 second minimum.*
Exception: Gas turbine cycle: 0.5 second minimum.
*Note: NFPA 101(00), Sec. 7.9.1.2 requires that emergency loads be picked up within 10 seconds.
Based on the review of facility's logs it could not be revealed if the generators meet the above guidelines since there was no transfer time or load pick up time indicated in the logs.
Note: It is important to verify that the emergency generator is capable of transferring the load as per the following requirements of every monthly load test:

NFPA 99 1999 - 3-4.3 Performance Criteria and Testing (Type 1 EES).
3-4.3.1 Source.
The branches of the emergency system shall be installed and connected to the alternate power source specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.

NFPA 99 1999- 3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1].

Findings were verified with Director of Facilities.

A. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13 1999 [Standard for the Installation of Sprinkler Systems], to provide complete coverage in the fully sprinklered Mural Pavilion.

Findings include:

During the tour of the Mural Pavilion on 01/07/14 at 3:00 PM, it was noted that the elevator machine room in the 4 th floor did not have any sprinkler head. Mural Pavilion is a fully sprinklered building and therefore as per NFPA 13 requires a sprinkler head in elevator machine room.

Findings were observed and verified with Director of and Director of Environmental and Health Services.

B. Based on observation, it was determined that the facility failed to provide a battery back up light for the generator of Kountz pavilion.

Findings include:

On 01/13/14 AT 4;00 PM , it was noted that the generator room/trailer, housing the generator for KP building, did not have an emergency battery powered back up light.

Note: Subsection 5-3.1 of NFPA 110 requires that:
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

C. Based on observation, facility did not ensure that the stairwell exit signs have all required information as per NFPA 101 7.2.2..5.4 and that they are installed in such a manner that they are readily visible in the open and closed position of the doors.

Findings include:

During the survey of Mural Pavilion on 01/07/14 at 12:15 PM, it was noted that the stairwell sign in the staircase did not have the information for roof access. An example of such was noted in Stair Well 'A' on the 3rd floor.

Note:
7.2.2.5.4* Stair Identification Signs.
Stairs serving five or more stories shall be provided with signage within the enclosure at each floor landing. The signage shall indicate the story, the terminus of the top and bottom of the stair enclosure, and the identification of the stair enclosure. The signage also shall state the story of, and the direction to, exit discharge. The signage shall be inside the enclosure located approximately 5 ft (1.5 m) above the floor landing in a position that is readily visible when the door is in the open or closed position.

Furthermore, on 01/13/14 at 2:45 PM, similar issue was noted in Women's pavilion. The signs in WP building only had identification of the stair well and not all other information as required by the code.

It was also noted during the facility's tour of all buildings that the stairwell signs were not always installed in a manner that vital egress information is seen by the occupants of a building and by fire fighters in case of emergency.

All above findings were verified with Chief Operating Officer and Director of Facilities along with engineering personal.

Based on document review and staff interview, it was determined that the facility performs general anesthesia and has emergency generators installed in the facility and thus requires a Type I EES (essential electrical system). The wiring of the electrical system at the panels on patient care floors in the Martin Luther King Pavilion are not in compliance with the code, NFPA 99 3-4, and generators are not divided into three branches.

Findings include:

1. On 01/09/14 in an interview with Director of Facilities at 1:30 PM, the Director of Facilities and Director of Engineering indicated that the wiring configuration in the MLK building for the Type I EES is not in compliance with 1999 NFPA 99 3-4.2.2.1.

The specific issue involved was that the separation of the generator branches into a life safety, critical, and equipment system was not done for the generators and panels on patient floors were not provided for segregating the three branches. Thus the panels at the main mechanical room/switch gear room/generator has mixed wiring for life safety, critical, and equipment branches in whatever panel is present in the facility and the wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System, and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch.

1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.


THIS IS A REPEAT CITATION FROM THE FULL FEDERAL SURVEY OF 2010.

The Facility was cited for this same issue and facility had responded that 'In accordance with new LSC standards for electrical distribution, as specified by NFPA 99 and NFPA 70, the existing TYPE 1 EES will be modified. The physical plant modernization project will ensure that all components in the plan are in accordance with NFPA 99. Facilities Management and Modernization Department will ensure that all components are incorporated into the plan according to NFPA 99 standards. The estimated completion date for the project is 2/2012'.

As per Director of Facilities. the facility started doing the project, managed to separate 6 out of 10 transfer switches ( those new 6 are dedicated to elevator) however the rest 4 still have mixed wiring. As per the Director of Facilities the reason why the project could not be completed in a timely manner was lack of resources/funds.

No information prior to the survey was ever provided to DOH or CMS regarding the facility's intention of extending the project due to circumstances and not completing as promised and indicated by their response in 2010.

A. Based on staff interview all electrical receptacles in patient care areas were not tested and maintained as per code.

Findings include:

On 01/13/14 at 3:00 PM, the Director of Facilities was requested to provide evidence that electrical receptacles in the patient care areas were tested. Director of Facilities and Director of Engineering stated stated there were no such records. The facility also did not have any policy and procedure in place regarding how often should it be conducted.

NOTE:
As per NFPA 1999 (99 ed) section 3-3.4.2.3 Maintenance and Testing of Electrical system Testing Interval for Receptacles in Patient Care Areas.

(1) Testing shall be performed after initial installation, replacement, or servicing of the device.

(2) Additional Testing shall be performed at intervals defined by documented performance data.

The codes of NFPA 99 1999 3-3.3.3 and 3-3.3.3.2 identify the most pertinent tests required to be verified.

Facility needs to ensure full compliance with NFPA 99 Chapter 3 and NFPA 70.

Facility needs to determine the frequency of testing by evidence based data and ensure that servicing of the electrical receptacles is done as per NFPA 99 so that all receptacles are operational with no electrical leakage or any other problem.

B. Based on observation, facility did not ensure that all in-patient bed locations have electrical receptacles getting its power from normal and emergency or have dedicated emergency power receptacles.

Findings included:

On 01/10/14 between 2;00 PM to 4:00 PM, during the tour of the Pediatric floor-MLK-17th floor and Maternity Floor -MLK-4th floor, it was noted that the receptacles by the bed side did not have any red outlets/emergency power outlets. There was no other indication or labeling that there are other receptacles apart from normal power that may assist in patient care in case of power outage

NOTE: NFPA 70
517-18. General Care Areas
(a) Patient Bed Location. Each patient bed location shall be supplied by at least two branch circuits, one from the emergency system and one from the normal system. All branch circuits from the normal system shall originate in the same panelboard.
Exception No. 1: Branch circuits serving only special-purpose outlets or receptacles, such as portable X-ray outlets, shall not be required to be served from the same distribution panel or panels.
Exception No. 2: Requirements of Section 517-18(a) shall not apply to patient bed locations in clinics, medical and dental offices, and outpatient facilities; psychiatric, substance abuse, and rehabilitation hospitals; sleeping rooms of nursing homes and limited care facilities meeting the requirements of Section 517-10(b)(2).
Exception No. 3: A general care patient bed location served from two separate transfer switches on the emergency system shall not be required to have circuits from the normal system.

C- Based on document review and staff interview, facility did not ensure that the electrical safety test was conducted on the patient care instruments as per frequency defined by NFPA 99.

Findings include:

On 01/09/14, facility was requested to provide electrical safety test for all equipments in the facility. The Director of Bio-med provided a policy and procedure titled ''Policy on Maintaining. Testing & Inspecting Med Equipment'. This policy did not include the frequency of electrical testing and was more geared towards the preventive maintenance of the equipment.

Furthermore, on 01/13/14 two equipment 'Pentamix' with serial number 978003002332 and M575106 were noted in the Dental Out-patient clinic and it was written on their preventive maintenance sticker that no re-inspection needed.

When the last preventive maintenance record was requested. it was found that they had their last electrical safety check on 07/12/03 (10 years back).

As per NFPA 99 section 7-6.2.1.2 Testing Intervals.
(a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance.
(b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:
General care areas - 12 months
Critical care areas - 6 months
Wet locations - 6 months
Exception No. 1: The testing intervals listed are intended to be nominal values, and facilities shall be permitted to adopt a protocol using either longer or shorter intervals provided that there is a documented justification based on previous safety testing records for the equipment in question, unusually light or heavy utilization, or similar considerations.
Exception No. 2: Facility-owned household or other appliances that are used in the patient care vicinity, but that are not intended to contact the patient, shall be tested at intervals deemed appropriate by the facility. Some equipment in this category requires only an infrequent visual inspection. The facility shall be permitted to structure a testing protocol and frequency for some equipment that might be more limited than that prescribed in 7-5.1.3.
Exception No. 3: The tests specified in 7-5.1.3.6, Lead Leakage Current Tests and Limits, Portable Equipment, shall be required only for incoming inspections and following repairs and modifications that might have compromised the patient lead leakage current.
Exception No. 4: * After the installation of fixed equipment, it shall be tested periodically in accordance with 3-3.3.2.3, and meet the following criteria:
(a) 500 mV for general care areas
(b) 40 mV for critical care areas

Facility did not comply with the above requirement.

Findings were verified with Director of Facilities and Chief Operating Officer.