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The facility did not ensure that the common wall of the non-conforming building was a fire barrier having at least a two-hour fire resistance rating constructed of materials required for the addition, as required by the referenced, "Life Safety Code" .

On 06/10/15 at 11:45 AM the surveyor while accompanied by the Director of Engineering and the Project Manager observed that the gap between the 2 (two) doors that serve as the building separation at the Center 8-ICU renovation project was excessive, was larger than 1/8-inch and no longer listed & approved as a 2-hr fire barrier as required by section # 19.1.1.4.3 of the referenced, "Life Safety Code" ;i.e. large gap between fire doors.

The facility did not ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch sold-bonded core wood, capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke and are provided with a means suitable for keeping the door closed as required by the LSC

On 06/09/15 at 1:20 PM, the surveyor along with the Facility Fire Marshal, Biomedical Equipment Department Manager and the Regional Vice President of Operations observed that the C9I corridor doors from patient rooms lacked positively latching when tested, and the door latching hardware had been removed.

The facility did not ensure that vision panels in corridor walls or doors were of fixed wired glass in approved frames, limited to 1296 square inch per panel, as required by the referenced " Life Safety Code "

On 06/10/15 at 11:20 AM the surveyor was not provided with documentation from the Director of Engineering or Project Manager to indicate that the glazing that was installed between the corridor and the waiting room for the Center 8-ICU renovation project was rated as safety glass and appropriate for installation within 18-inches of the finished floor, as required by section # ' s 19.3.6.2.3 & 19.3.6.3.8 of the referenced " Life Safety Code ";i.e. docs not provided before nursing unit was placed into service;

The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the referenced LSC.
On 06/08/15 at 10:42 AM the surveyor, accompanied by a representative of the Hartford Hospital Fire Department, observed that corridor door for the 3 North egress stair tower in the Donnelly Building is damaged to the core, negating the assembly ' s ability to resist the passage of smoke as required by the referenced LSC standard.

The facility did not ensure that access to exits are marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants as required by section 7.10.1.4 of the LSC
On 06/08/15 at 1:35 PM the surveyor, accompanied by a representative of the Hartford Hospital Fire Department, observed that the exit access paths and exit doors on the second (2nd) floor of the Gengras Building were not marked as required by section 7.10 of the LSC.

The facility did not ensure that smoke barriers were constructed to provide at least a ½ hour fire resistance rating, as required by section # ' s 8.3 and 19.3.7.3 of the "Life Safety Code" .

On 06/10/15 at 11:50 AM the surveyor while accompanied by the Director of Engineering and the Project Manager observed that the smoke barrier wall between the patient room and the nurses station for the Center 8-ICU renovation project was breached by a steel, I-beam and the voids & gaps around the penetration were not sealed with materials having at least a ½ hour fire resistance rating, as required by section # ' s 8.3 and 19.3.7.3 of the "Life Safety Code" ; i.e. large gaps can be seen on the patient room side of the wall above the ceiling.

The facility did not ensure that hazardous areas were either separated by construction providing at least a one hour fire resistance rating or protected by an automatic extinguishing system, where the sprinkler option is used the areas shall be separated by smoke resisting partitions and self-closing doors as required by 19.3.2.1
On 06/09/15 at 09:45 AM the surveyor, accompanied by a representative of the Engineering Department, observed that corridor door for the Biohazard Storage Room in the basement between the High Building and the South Building had gaps and openings around the door frame that when in the closed position, failed to maintaine the required resistance to the passage of smoke as required by the referenced LSC standard.



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The facility did not ensure that hazardous areas were separated by smoke resisting partitions and self-closing doors as required by section # 19.3.2.1 of the " Life Safety Code "

On 06/10/15 at 11:15 AM the surveyor while accompanied by the Director of Engineering and the Project Manager observed that the Storage Room (located in the Center 8-ICU renovation project-Room # H863) doors (2) were not provided with self-closing devices, as required the " Life Safety Code ";i.e. 2 hr. room-no self-closers on doors.

The facility did not ensure that hazardous areas were separated by smoke resisting partitions and self-closing doors as required by section # 19.3.2.1 of the " Life Safety Code "

On 06/10/15 at 11:15 AM the surveyor while accompanied by the Director of Engineering and the Project Manager observed that the Storage Room (located in the Center 8-ICU renovation project-Room # H863) doors (2) were not provided with self-closing devices, as required the " Life Safety Code ";i.e. 2 hr. room-no self-closers on doors.

The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift, as required by the referenced " Life Safety Code " .

On 06/09/15 at 10:35 AM, the surveyor was provided with documentation from the Electrical Manager to indicate that fire drills were conducted at the West Hartford (Blueback Square) Surgery Center; i.e. documentation provided indicates fire alarm not activated during any fire drills, as required by the" Life Safety Code " .

The facility did not ensure that there is an automatic sprinkler system installed in accordance with NFPA 13, " Standard for the Installation of Sprinkler Systems ", to provide complete coverage for all portions of the building.

On 06/09/15 at 1:00 PM, the surveyor was provided with documentation from the Electrical Manager to indicate that working plans for the new, sprinkler system at Newington Eye Surgery Center were submitted for approval to the authority having jurisdiction (CT DPH) before any equipment was installed or remodeled, as required by section # 8-1 of NFPA 13, "Standard for the Installation of Sprinkler Systems "; i.e. sprinkler system nearly complete at ASC-no departmental approvals issued.

The facility did not ensure that heating, ventilating, and air conditioning equipment have been installed compliant with section 9.2 and in accordance with the manufacturers ' specifications.
On 06/08/15 at 09:40 AM the surveyor, accompanied by a representative of the Hartford Hospital Fire Department, observed that all of the domestic clothes dryers installed throughout the Donnelly Building are not installed to the standards set forth by section 504.6 of the International Mechanical Code. i.e; all dryers were observed as not be supported and secured in place, and male end of all ductwork did not overlap joints in the direction of the air flow.

The facility did not ensure that means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10
On 06/08/15 at 11:45 AM the surveyor, accompanied by a representative of the Hartford Hospital Fire Department, observed that the clothes lockers installed within the egress corridor of the CARES Unit within the Donnelly Building were constructed of a combustible material, not metal as required by the referenced LSC standard.

The facility did not ensure that draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies are flame resistant in accordance with section # 10.3.1 of the referenced, Life Safety Code, NFPA 13, "Standard for the Installation of Sprinkler Systems " and NFPA 701.

On 06/08/15 at 10:20 AM and at different times throughout the day, the surveyor, while accompanied by Mechanical Manager observed that the patient cubicle curtains throughout the 4th floors of the Core, Bliss, High and South Buildings were torn, ripped, soiled, damaged and no longer maintainable, as required by section # 10.3.1 of the "Life Safety Code " , NFPA 13, "Standard for the Installation of Sprinkler Systems " and NFPA 701; i.e. the cubicle curtains throughout these areas shall be repaired or replaced;

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and mobil, soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the referenced " Life Safety Code " .

On 06/08/15 at 10:00 AM the surveyor, while accompanied by Mechanical Manager observed that throughout the 4th floors of the Core, Bliss, High and South Buildings soiled linen and trash collection receptacles that had capacity greater than 32 gallons that were placed in corridors i.e. receptacles used for soiled linen and trash throughout the operating room areas with capacities greater than 32 gallons not being stored in rooms protected as hazardous areas as required by section # 19.7.5.5 of the " Life Safety Code " .

Note: This is a repeat observation from the surveys in 2011 & 2012 and the Plan of Corrections from those surveys for this violation has not been followed.

The facility did not ensure that piped in medical gas systems are in compliance with sections 4.1, 4.1.1 NFPA 99 " Health Care Facility ' s " , and NFPA 70, " National Electrical Code " .

On 06/09/15 at 2:00 PM, the surveyor was provided with documentation from the Electrical Manager to indicate that the new, medical gas system that is being installed at Newington Eye Surgery Center in accordance with section # 4-3.1.2.10 of NFPA 99 " Health Care Facilities";i.e. medical gas system nearly complete at ASC-no departmental approvals issued.

The facility did not ensure that penetrations of smoke barriers by ducts are protected in accordance with section # 8.3.5 of the referenced "Life Safety Code ".

On 06/09/15 at 10:45 AM, the surveyor was provided with documentation from the Electrical Manager to indicate that the smoke dampers throughout the West Hartford Surgical Center were inspected at least annually, as required by NFPA 72, " National Fire Alarm & Signal Code " , Table # 7-3.2; i.e. J Glaski report of 2011 indicates smoke dampers not inspected since 2009.

The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99, " Health Care Facilities " ;
On 06/09/15 at 10:30 AM, the surveyor was provided with documentation from the Electrical Manager to indicate that all of the electrical receptacle outlets in patient areas at the facility are inspected annually as required by sections 3-3.3.3 & 3-3.4.2.3 of NFPA 99, " Health Care Facility ' s " and as part of the facility ' s preventive maintenance program; i.e. staff reports that testing is only done when nursing units are renovated or don ' t have patients.

1. The facility did not ensure that electrical wiring and equipment is in accordance with NFPA 70, "National Electrical Code " , as required by section # 9.1.2 of the referenced, "Life Safety Code "

On 06/10/15 at 11:40 AM the surveyor while accompanied by the Director of Engineering and the Project Manager observed that the electrical service panel labeled as PP8C1 located in the electrical panel closet located in the renovated, Center 8, ICU nursing unit was not provided with a proper circuit (breaker) legend or a device to cover the exposed, (energized) buss bar within the panel, as required by NFPA 70, "National Electrical Code " ; i.e. facility staff opened nursing unit before required documentation was provided.
2. The facility did not ensure that electrical wiring and equipment is in accordance with NFPA 70, "National Electrical Code " , as required by section # 9.1.2 of the referenced, "Life Safety Code "

On 06/08/15 at 10:10 AM the surveyor, while accompanied by Mechanical Manager observed that non-listed & approved electrical, power/plug strips were in use at patient care areas on the portable workstations throughout the 4th floors of the Core, Bliss, High, Jefferson and South Building; i.e. cords in operating rooms not hospital grade or otherwise approved for use in these areas;