HospitalInspections.org

Based on observations during a 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 located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type I (332).

The findings are:

On 10/23/12 to 10/24/12 between 11:00 AM to 4:00 PM, it was observed that in
the Medical Art Pavilion (MAP) -Moses campus and Einstein Campus, the ceiling assembly located throughout the building was comprised of lay-in ceiling tiles. Observations above the suspended ceilings revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above were not completely protected with a fire resistive material.

Examples of some unprotected I-beams including but not limited to are:

i. Areas of the I-beam in the mechanical /air-duct handling rooms in all the floors of the MAP building

ii. I-beam above the drop ceiling outside the Kitchen in Einstein Campus.

Findings were verified with Vice President of the Facilities during time of observation.

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 observation and interview, it was determined that the facility did not ensure that all doors opening onto and protecting the corridors from fire/smoke were kept free of impediments to ensure positive latching and quick closing of the doors in case of an emergency.

Findings include:

1. During observations of the Wakefield Campus and Einstein Campus on 10/16/12, 10/18/12 and 10/24/12 between 11:00 AM to 3:00 PM, it was noted that the rooms opening into the common exit corridor were kept prop open by cords tied from the door knob to buckets or similar items in front of the door.

Examples, including but not limited to, are:

a. The Generator room in the Wakefield Campus was noted propped open by a bucket of paint/plaster. This situation was not only impeding the prompt closure of the door but also compromising the 2 hour rating of the room for any fire emergency in the generator room that may extend to the corridor.

b. The rear door of the kitchen that opened onto the corridor was noted held open by a cord tied from the latch /handle to the hook on the wall behind the door.

c. The house keeping room door in the basement of Einstein Campus opening to the corridor was propped open by placing a bucket in front of the door.

All findings were verified with Director of Engineering at Wakefield Campus and Vice President of Facilities at Einstein at the time of the observations.

NFPA 101 (2000 edition) 19.2.1, 19.3.6.3, (19.3.6.3.6), 7.2.

Based on observation, the facility failed to ensure that adequate exit signage was provided.

The findings were:

During a tour of the kitchen and the food service area on the morning of 10/17/2012, the following were identified and brought to the attention of the VP of facilities and the Director of Food services & nutrition and the Director of Engineering who acknowledged the findings:
1. No illuminated exit sign for the hot production area of the kitchen.
2. No exit sign was provided in the dry storage area of the kitchen.
3. No illuminated exit sign was provided in the corridor of the silver zone of the radiology department that was also referred to as the staff corridor.
4. The carpenter shop did not have an exit sign to direct the staff to the exit in the event of fire or smoke.

Based on observations, the facility failed to ensure that smoke barriers were constructed and maintained to resist the passage of smoke.
Findings include:
1. The wall of the smoke barrier on the 10th floor of Cham building of room 1009 did not extend to the deck above, and had a gap of approximately 6 inches of penetration between the wall and the deck above.
2. The fire rated wall at the elevator service bank had a penetration that was not sealed with the proper fire stops. The penetrations were sealed with a white colored material. The staff could not produce documented evidence to prove that material has the correct fire rating, and was UL listed fire stops.

Based on observation on 10/21/12, the facility failed to ensure that exit access corridors were unobstructed and at least 4 feet wide in the Medical Art Pavillion (MAP)-Mosses Campus.

Findings:

On 10/21/12 at 11:30 AM, during the tour of the facility MAP building it was noted that two to three EKG machines were kept/stored in the Exit Access corridor on the 8th floor opposite the examination rooms for adult primary health care). The width of the corridor was reduced to approximately 36 inches.

It is to be noted that as per code corridors which may be used as the primary or secondary means of Exit access should be at least 44 inches wide

Findings were verified with VP-Facilities and Administration of PHC 8th floor.

NFPA 101-2000: 21.2.3.2

Based on document review and staff interview at the Wakefield and the Einstein Campus, 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 10/10/17/12 at 3:30 PM noted that the fire drill report is in the form of a checklist highlighting few points of the drill on which the 'observer' of the drill 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 indicated in bullet #3 that the fire drill is begun by (a) fire drill cards handed out (b) smoke detector set off (pull station pulled and (d) others.
Most of the drills had "pull station pulled" marked off as how the drill began but this information is incomplete as it does not give information for the various scenarios.

The Director of Engineering (DOE) provided a fire drill record dated 07/16/12 for an OR fire condition at the Wakefield Campus (WC). This drill did not have any information regarding how this OR fire drill was different that any other fire drills keeping in view the OR environment is different and more complexed than any other environment of the facility.
The drill stated 'OR Scenario' did not have any comments section or attachment regarding 'what was the scenario'.

Furthermore, the DOE of WC stated that he participated in the drill, however his signature was not on the sign in sheet. Therefore, it could not be verified, nor determined how the facility ensured that it keeps up-to-date records of all participants, and that all the staff complete their mandatory drills.

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


Findings were verified with Director of Fire Safety

Based on observation, it was determined that 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:

During the tour of the Wakefield Campus 10/15 from 11:00 AM to 3:30 PM, it was observed that the exposed sprinkler pipes in various parts of the facility exhibited accumulation of lint, dust, and paint specks.

Examples including but not limited to are:

i. Three sprinkler heads in the sterile supply storage room of the OR suite were noted having dust, dirt and paint on them.

ii. There were dusty sprinkler heads found in the Central Sterile Supply Workroom.

iii. In the linen closet of the 5 North Med/Surge unit , a piece of plastic bag was noted stuck to the sprinkler head.

iv. The janitorial closet in the corridor outside the ICU had a sprinkler head with paint on it.

Findings were verified with Director of Engineering

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

The findings were:
1. The corridor of the 7th floor of the Cham building was blocked by three (3) stretchers.
2. Two clean linen plastic containers (each one of them was 3 ft. x 5ft x 6ft in diameter) were stored on the corridor and blocking an area in front of the PACU.
3. The central corridor of the Operative Suite next to OR 15 was partly blocked by three (3) supplies carts, three (3) C- arm machines and robot surgery equipment.

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

The findings include:

During the survey from 10/15/12 to 10/25/12 between 1:00 AM to 4:00 PM, it was observed that the facility had provided decorative artificial plants about 4.0-5.0 feet tall in various areas/campuses of the facility.

An interview with Director of Engineering and VP of Facilities at the time of observations revealed that they could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. They stated that they did not think that those plants were rendered flame retardant by any chemical treatment.


For areas found with artificial plants refer to Tag A 701

Based on observation in the Wakefield campus, Medical Art Pavilion and Einstein campus, 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

Findings include:

During the tour of the three facilities from 10/16/12 to 10/25/12 from 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 were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes. These penetrations were not completely sealed all around with an approved fire retardant material to prevent passage of smoke from one compartment to the other.

Examples, including but not limited to include:

a. On 10/16/12, during the tour of the Main Clean Linen Storage / laundry room-WC, it was noted that the Telecom IT Hub room had miscellaneous penetrations of the fire rated wall with improperly sealed ducts. There were similar penetrations seen on different rated walls of the room made via cables, ducts and wires.
The fire door also had penetrations above the drop ceiling.

b. On 10/17/12 , during the tour of the Radiology Department-WC it was noted that the fire wall outside the file room, the smoke wall by the reading room, and the smoke barrier in the corridor had penetrations.

c. On 10/23/12, the IT/electrical closet and Mechanical/air-handling rooms in the MAP building had missing fire retardant around various penetrations of the rated wall. The head to the wall joint in the IT/Electrical room was not correctly sealed all along the wall.

d. On 10/24/12 during the inspection of the fire walls in the Einstein Campus various penetrations were noted above the drop ceiling of the fire door by the kitchen, in the basement corridor by the fire rated Main Linen Storage room, by the Emergency Department Locker room and by the one- hour fire rated double door.

These findings were verified with the Director of Engineering at Wakefield Campus and the VP-Facilities and Director of Engineering at the MAP -Moses building and Einstein Campus.

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 lack of documentation, it could not be verified if the facility divided the Type I EES into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2. (1999 edition code).
It is to be noted that the facility performs general anesthesia and has Type I EES (essential electrical system) emergency generators installed in the Einstein Campus.

Findings include:

On 10/25/12 at 11:30 AM, the surveyor requested that the Director of Engineering and Vice President of Facilities provide information regarding the three branches of the emergency generator specifically regarding how were they separated.

The staff stated that the generator has three branches, however no information was provided for the three branches distribution and the specific areas served.

It is important to determine that the wiring for items required to be served by the Equipment System are independent from wiring for items required to be served by the Emergency System.

The wiring for items required to be served by the Emergency System - Life Safety Branch are 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.

Furthermore, the Life Safety branch cannot serve anything other than the seven items listed.

NOTE:NFPA 99 3-4.2.2.1(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:

1. Illumination of means of egress as required in NFPA 101,® Life Safety Code®

2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code

3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems ".

4. Hospital communication systems where used for issuing instruction during emergency conditions.

5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location.

6. Elevator cab lighting, control, communication, and signal systems.

7. Automatically operated doors used for building egress. No function
other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

Based on document review it could not be verified if all elevator banks in the Einstein Campus that have or require fire fighter Phase I and Phase II recall were tested as per code requirement.

Findings include:

On 10/24/12 at 12:30 PM, the Director of Engineering at the Einstein Campus was requested to provide information regarding the fire fighter recall feature on all the elevators in the facility. He provided a letter from 'Schindler Elevator' dated 10/19/12 indicating that all cars in the facility met city code for fire fighter service Phase 1 and Phase 2.

During documentation review of the test on elevators by the fire department company there was no test results for elevator 'D'.
The DOE stated that this elevator (although traveling more than 25 feet) is not equipped with a fire fighter feature however, the drawing by the onsite elevator maintenance staff indicated it was indeed equipped. If all connections were active for the fire fighter feature it was not verified at the time of survey.

Therefore, it could not be determined how the facility ensures that all elevators that have or required fire fighter features are periodically tested as per the code.

NOTE: NFPA 101 2001 9.4.6 Elevator Testing.

Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators.
All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators.

Based on observations during a 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 located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type I (332).

The findings are:

On 10/23/12 to 10/24/12 between 11:00 AM to 4:00 PM, it was observed that in
the Medical Art Pavilion (MAP) -Moses campus and Einstein Campus, the ceiling assembly located throughout the building was comprised of lay-in ceiling tiles. Observations above the suspended ceilings revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above were not completely protected with a fire resistive material.

Examples of some unprotected I-beams including but not limited to are:

i. Areas of the I-beam in the mechanical /air-duct handling rooms in all the floors of the MAP building

ii. I-beam above the drop ceiling outside the Kitchen in Einstein Campus.

Findings were verified with Vice President of the Facilities during time of observation.

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 observation and interview, it was determined that the facility did not ensure that all doors opening onto and protecting the corridors from fire/smoke were kept free of impediments to ensure positive latching and quick closing of the doors in case of an emergency.

Findings include:

1. During observations of the Wakefield Campus and Einstein Campus on 10/16/12, 10/18/12 and 10/24/12 between 11:00 AM to 3:00 PM, it was noted that the rooms opening into the common exit corridor were kept prop open by cords tied from the door knob to buckets or similar items in front of the door.

Examples, including but not limited to, are:

a. The Generator room in the Wakefield Campus was noted propped open by a bucket of paint/plaster. This situation was not only impeding the prompt closure of the door but also compromising the 2 hour rating of the room for any fire emergency in the generator room that may extend to the corridor.

b. The rear door of the kitchen that opened onto the corridor was noted held open by a cord tied from the latch /handle to the hook on the wall behind the door.

c. The house keeping room door in the basement of Einstein Campus opening to the corridor was propped open by placing a bucket in front of the door.

All findings were verified with Director of Engineering at Wakefield Campus and Vice President of Facilities at Einstein at the time of the observations.

NFPA 101 (2000 edition) 19.2.1, 19.3.6.3, (19.3.6.3.6), 7.2.

Based on observation, the facility failed to ensure that adequate exit signage was provided.

The findings were:

During a tour of the kitchen and the food service area on the morning of 10/17/2012, the following were identified and brought to the attention of the VP of facilities and the Director of Food services & nutrition and the Director of Engineering who acknowledged the findings:
1. No illuminated exit sign for the hot production area of the kitchen.
2. No exit sign was provided in the dry storage area of the kitchen.
3. No illuminated exit sign was provided in the corridor of the silver zone of the radiology department that was also referred to as the staff corridor.
4. The carpenter shop did not have an exit sign to direct the staff to the exit in the event of fire or smoke.

Based on observations, the facility failed to ensure that smoke barriers were constructed and maintained to resist the passage of smoke.
Findings include:
1. The wall of the smoke barrier on the 10th floor of Cham building of room 1009 did not extend to the deck above, and had a gap of approximately 6 inches of penetration between the wall and the deck above.
2. The fire rated wall at the elevator service bank had a penetration that was not sealed with the proper fire stops. The penetrations were sealed with a white colored material. The staff could not produce documented evidence to prove that material has the correct fire rating, and was UL listed fire stops.

Based on observation on 10/21/12, the facility failed to ensure that exit access corridors were unobstructed and at least 4 feet wide in the Medical Art Pavillion (MAP)-Mosses Campus.

Findings:

On 10/21/12 at 11:30 AM, during the tour of the facility MAP building it was noted that two to three EKG machines were kept/stored in the Exit Access corridor on the 8th floor opposite the examination rooms for adult primary health care). The width of the corridor was reduced to approximately 36 inches.

It is to be noted that as per code corridors which may be used as the primary or secondary means of Exit access should be at least 44 inches wide

Findings were verified with VP-Facilities and Administration of PHC 8th floor.

NFPA 101-2000: 21.2.3.2

Based on document review and staff interview at the Wakefield and the Einstein Campus, 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 10/10/17/12 at 3:30 PM noted that the fire drill report is in the form of a checklist highlighting few points of the drill on which the 'observer' of the drill 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 indicated in bullet #3 that the fire drill is begun by (a) fire drill cards handed out (b) smoke detector set off (pull station pulled and (d) others.
Most of the drills had "pull station pulled" marked off as how the drill began but this information is incomplete as it does not give information for the various scenarios.

The Director of Engineering (DOE) provided a fire drill record dated 07/16/12 for an OR fire condition at the Wakefield Campus (WC). This drill did not have any information regarding how this OR fire drill was different that any other fire drills keeping in view the OR environment is different and more complexed than any other environment of the facility.
The drill stated 'OR Scenario' did not have any comments section or attachment regarding 'what was the scenario'.

Furthermore, the DOE of WC stated that he participated in the drill, however his signature was not on the sign in sheet. Therefore, it could not be verified, nor determined how the facility ensured that it keeps up-to-date records of all participants, and that all the staff complete their mandatory drills.

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


Findings were verified with Director of Fire Safety

Based on observation, it was determined that 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:

During the tour of the Wakefield Campus 10/15 from 11:00 AM to 3:30 PM, it was observed that the exposed sprinkler pipes in various parts of the facility exhibited accumulation of lint, dust, and paint specks.

Examples including but not limited to are:

i. Three sprinkler heads in the sterile supply storage room of the OR suite were noted having dust, dirt and paint on them.

ii. There were dusty sprinkler heads found in the Central Sterile Supply Workroom.

iii. In the linen closet of the 5 North Med/Surge unit , a piece of plastic bag was noted stuck to the sprinkler head.

iv. The janitorial closet in the corridor outside the ICU had a sprinkler head with paint on it.

Findings were verified with Director of Engineering

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

The findings were:
1. The corridor of the 7th floor of the Cham building was blocked by three (3) stretchers.
2. Two clean linen plastic containers (each one of them was 3 ft. x 5ft x 6ft in diameter) were stored on the corridor and blocking an area in front of the PACU.
3. The central corridor of the Operative Suite next to OR 15 was partly blocked by three (3) supplies carts, three (3) C- arm machines and robot surgery equipment.

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

The findings include:

During the survey from 10/15/12 to 10/25/12 between 1:00 AM to 4:00 PM, it was observed that the facility had provided decorative artificial plants about 4.0-5.0 feet tall in various areas/campuses of the facility.

An interview with Director of Engineering and VP of Facilities at the time of observations revealed that they could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. They stated that they did not think that those plants were rendered flame retardant by any chemical treatment.


For areas found with artificial plants refer to Tag A 701

Based on observation in the Wakefield campus, Medical Art Pavilion and Einstein campus, 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

Findings include:

During the tour of the three facilities from 10/16/12 to 10/25/12 from 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 were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes. These penetrations were not completely sealed all around with an approved fire retardant material to prevent passage of smoke from one compartment to the other.

Examples, including but not limited to include:

a. On 10/16/12, during the tour of the Main Clean Linen Storage / laundry room-WC, it was noted that the Telecom IT Hub room had miscellaneous penetrations of the fire rated wall with improperly sealed ducts. There were similar penetrations seen on different rated walls of the room made via cables, ducts and wires.
The fire door also had penetrations above the drop ceiling.

b. On 10/17/12 , during the tour of the Radiology Department-WC it was noted that the fire wall outside the file room, the smoke wall by the reading room, and the smoke barrier in the corridor had penetrations.

c. On 10/23/12, the IT/electrical closet and Mechanical/air-handling rooms in the MAP building had missing fire retardant around various penetrations of the rated wall. The head to the wall joint in the IT/Electrical room was not correctly sealed all along the wall.

d. On 10/24/12 during the inspection of the fire walls in the Einstein Campus various penetrations were noted above the drop ceiling of the fire door by the kitchen, in the basement corridor by the fire rated Main Linen Storage room, by the Emergency Department Locker room and by the one- hour fire rated double door.

These findings were verified with the Director of Engineering at Wakefield Campus and the VP-Facilities and Director of Engineering at the MAP -Moses building and Einstein Campus.

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 lack of documentation, it could not be verified if the facility divided the Type I EES into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2. (1999 edition code).
It is to be noted that the facility performs general anesthesia and has Type I EES (essential electrical system) emergency generators installed in the Einstein Campus.

Findings include:

On 10/25/12 at 11:30 AM, the surveyor requested that the Director of Engineering and Vice President of Facilities provide information regarding the three branches of the emergency generator specifically regarding how were they separated.

The staff stated that the generator has three branches, however no information was provided for the three branches distribution and the specific areas served.

It is important to determine that the wiring for items required to be served by the Equipment System are independent from wiring for items required to be served by the Emergency System.

The wiring for items required to be served by the Emergency System - Life Safety Branch are 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.

Furthermore, the Life Safety branch cannot serve anything other than the seven items listed.

NOTE:NFPA 99 3-4.2.2.1(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:

1. Illumination of means of egress as required in NFPA 101,® Life Safety Code®

2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code

3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems ".

4. Hospital communication systems where used for issuing instruction during emergency conditions.

5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location.

6. Elevator cab lighting, control, communication, and signal systems.

7. Automatically operated doors used for building egress. No function
other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

Based on document review it could not be verified if all elevator banks in the Einstein Campus that have or require fire fighter Phase I and Phase II recall were tested as per code requirement.

Findings include:

On 10/24/12 at 12:30 PM, the Director of Engineering at the Einstein Campus was requested to provide information regarding the fire fighter recall feature on all the elevators in the facility. He provided a letter from 'Schindler Elevator' dated 10/19/12 indicating that all cars in the facility met city code for fire fighter service Phase 1 and Phase 2.

During documentation review of the test on elevators by the fire department company there was no test results for elevator 'D'.
The DOE stated that this elevator (although traveling more than 25 feet) is not equipped with a fire fighter feature however, the drawing by the onsite elevator maintenance staff indicated it was indeed equipped. If all connections were active for the fire fighter feature it was not verified at the time of survey.

Therefore, it could not be determined how the facility ensures that all elevators that have or required fire fighter features are periodically tested as per the code.

NOTE: NFPA 101 2001 9.4.6 Elevator Testing.

Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators.
All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators.