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The facility did not ensure that corridors were separated from use areas by walls constructed with at least 30 minutes rating as required by the LSC.
On 02/07/11, 02/08/11 and 02/09/11 at 10:35 AM on the first date and at other various times, the surveyor, accompanied by the Director of Fiscal Services and Plant Operations and staff members from the facility ' s Fire Department and plant engineering observed that the corridor walls above the suspended ceiling in Woodward and Battell Halls contained voids and penetrations into resident dorms and other ancillary spaces that were not sealed with materials having at least a half hour fire resistance rating as required in a unsprinklered facility in order to maintain the least ? hour fire resistance rating of the corridor from use areas.

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 1? inch sold-bonded core wood, capable of resisting fire for at least 20 minutes.

On 02/08/11 at 10:35 AM, during a tour of Battell Hall inpatient units, the surveyor, accompanied by the Director of Fiscal Services and Plant Operations, the Fire Chief of the facility and a representative of Facilities Plant Engineering, observed that the 4 South doors to the dorms had holes from hardware that had been removed and the fire door into 1 north was damaged to the core, which do not meet the requirement of the LSC.

The facility did not ensure that the service/pipe/wire chase between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the referenced LSC.

On 02/08/11 at 11:00 AM and times throughout the day, the surveyor while accompanied by the Director of Fiscal Services and Plant Operations, a representative of the facility Fire Department and Facilities Plant Engineering observed the following:

a. the service chase serving the floors in Battell Hall on floors 3 and 4 had voids around penetrations for wires, pipes and conduit, which were not sealed using an UL Listed system for fire- stopping 1 hr. rated enclosures; i.e. fire-stopping caulk was applied on only one side and non-rated fire backing materials were used.

b. the service chase serving the basement, first and second floors of Woodward Hall had voids around penetrations for wires, pipes and conduit, which were not sealed using an UL Listed system for fire- stopping 1 hr. rated enclosures; i.e. fire-stopping caulk was applied on only one side and non-rated fire backing materials were used.

The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

On 02/07/11 at 10:13 AM and at other times throughout the day, the surveyor while accompanied by the Physical Plant Engineer I and Physical Plant Superintendant, observed that the smoke barriers on Merritt Building, floors 2 & 4 had voids around penetrations for the passage of sprinkler pipes and wires, which were not sealed using a UL Listed system for fire stopping through a smoke barrier; i.e. on 4G there were voids around penetrations in the wall above the ceiling in the storage closet; on 4F the fire stopping material was removed from around and inside the conduit above the ceiling, leaving the mineral wool exposed; in the 2G pipe chase room, there were voids around plumbing and cable cord penetrations.

The facility did not ensure that door openings in smoke barriers have at least a 20-minute fire protection rating or are at least 1?-inch thick solid bonded wood core and are self-closing or automatic closing in accordance with the referenced LSC 19.2.2.2.6.

a. on 02/07/11 at 10:13 AM and at other times throughout the day, the surveyor while accompanied by the Physical Plant Engineer I and Physical Plant Superintendant, observed that the doors that are located within the smoke barrier walls in Merritt Building, 4th floor were not provided with functional, self-closing devices; i.e. the hydraulic closer on the door to the Wing 4G storage closet was not functioning and the hydraulic closer on the door to the Wing 4F AED closet had been removed.

b. on 02/07/11 at approximately 10:35 AM and times throughout the day while touring the Woodward Hall, the surveyor while accompanied by the Director of Fiscal Services and Plant Operations, a representative of the facility Fire Department and Facilities Plant Engineering observed that the double doors to the patient dorms lacked door coordinators as required.

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.

On 02/07/11 at 11:45 AM The surveyor while accompanied by the Director of Fiscal Services and Plant Operations, a representative of the facility Fire Department and Facilities Plant Engineering observed that the Woodward Hall main electrical room and elevator machine room had voids around penetrations used for the passage of wires and conduit that were not sealed with materials that would maintain the required resistance to the passage of fire and/or smoke.

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 LSC.

1. on 02/ 09/11 at 11:00 AM, the surveyor was not provided with documentation from the Physical Plant Engineer II, the clinical staff or the Agency Police Officer (APO) to indicate that a 3rd shift, fire drill had been conducted at 500 Vine Street during the 3rd quarter of 2010 and that 2nd shift, fire drill had been conducted in the 4th quarter of 2010.

2. on 02/09/11 at 10:00 AM during documentation review, the surveyor observed that the facility was conducting silent fire drills in all the quarters throughout the year 2010 and in 2011during the day shift. Subsequent interview of the Chief and Assistant Fire Chief revealed that they were not aware that the fire drills exception in the LSC 19.7.1.2 only allows silent drills utilizing a coded announcement between the hours of 9:00 PM through 6:00 AM.

The facility did not ensure that a fire alarm system, with approved component devices or equipment was installed to provided effective warning of fire in any part of the building as required by the referenced LSC.

a. on 02/09/11at 9:00 AM, the surveyor was not provided with documentation that the newly installed (12/2010) fire alarm system was installed according to plans and tested and approved by the State Fire Marshal to ensure compliance with the CFSC, the LSC and NFPA 70 & 72.

b. on 02/09/11at 9:00 AM, the surveyor observed that the facility had signs posted for the Page Hall that the audible portion of the fire alarm notification devices within the building were not functioning and that in the event of fire, to listen for an overhead page for instructions.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

a. on 02/09/11 at 10:00 AM, the surveyor was not provided with documentation by Plant Facilities Staff that the necessary maintenance items identified on the sprinkler test reports had been completed, i.e.5th year obstruction investigation and all required 5th tear maintenance, 3rd year full flood test and annual trip testing of the dry pipe valves as identified on the 2009 and 2010 FPT sprinkler inspection reports

b. on 02/09/11 at 10:00 AM, the surveyor was not provided with documentation by Plant Facilities Staff that the sprinkler system had been inspected in the 4th quarter of 2010 as required by NFPA 25 " Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems " .

The facility did not ensure that the design, installation and use of its commercial cooking equipment was in accordance with NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations as required by the referenced LSC.

On 02/09/11at 10:00 AM, the surveyor was not provided with documentation by Plant Facilities Staff to indicate that the new cooking hood and fire protection system installed during the 2010 renovation of the Battell Hall/ Main Campus Kitchen had been installed according to plans and approved according to NFPA 96 1-1.1 & 1-1.2 i.e. no sign off from the Office of the State Fire Marshal. Subsequent interview of the Plant Facilities staff and Fire Department staff revealed that no notification to the Office of the State Fire Marshal had been made.

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.
On 02/07/11and 02/08/11at 9:30 AM and various other times throughout the day, the surveyor while accompanied by the Director of Fiscal Services and Plant Operations, a representative of the facility Fire Department and Facilities Plant Engineering observed the following:

a. The stairwell areas of refuge for Woodward 1 South and 2 South were being used for wheel chair storage and a wheelchair was being charged in the refuge area for Woodward 1 South;

b. the exit access and the exit from the auditorium for Battell 1 South into the stairwell was blocked by tables chairs and assorted furnishings;
c. the southeast exit access from the kitchen by the dietary office and the exit itself were partially blocked by rack storage of canned and dry goods.
d. the stair tower in Unit #5 of Whiting Forensic was being utilized as a storage area

1. The facility did not ensure that electrical devices in-patient areas were being inspected as required in NFPA 99 " Health Care Facility ' s "

On 02/07/11 at 11:27 AM the surveyor while accompanied by the Physical Plant Engineer I and Physical Plant Superintendant, observed that the electric, resident, beds located in Merritt Building, floor 3F, Room 14 lacked preventive maintenance stickers and the facility failed to provide documentation that all patient electrical devices in-patient areas are inspected as required in NFPA 99, Section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facility ' s preventive maintenance program; i.e. 2 electric beds in room-1 has no sticker and other bed sticker indicates PM/service due on 02/02/11-Superintendant asked for current documentation

2. The facility did not ensure that all employees are periodically instructed as to their duties during a fire emergency as required by NFPA 101 " Life Safety Code " 19.7.1 and annually as required in NFPA 99 " Health Care Facility ' s " 11-5.3.8.

a. On 02/09/11 at 11:00 AM, the surveyor was not provided with documentation from the Physical Plant Engineer II, the clinical staff or the Agency Police Officer (APO) that indicated all employees at 500 Vine Street are in serviced annually as to their duties during a fire emergency; i.e. clinical staff believes there are 96 staff members at 500 Vine Street and believes records/documentation of staff in service, fire safety training is located at Main Campus-documentation requested, never provided;
b. On 02/09/11 at 11:00 AM, the surveyor was not provided with documentation by the Plant Facilities Staff on the day of survey that indicated all employees on the Connecticut Valley Hospital main campus had been in serviced annually as to their duties during a fire emergency.

3. 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 02/09/11 at 11:00 AM, the surveyor was not provided with documentation that the facility had instituted a testing program for the electrical receptacles that had been replaced throughout the facility and subsequent interview of Plant Facilities Staff identified that they were going to go to between a 3 to 5 year time span for testing. Documented performance data to support the extension allowed for hospital grade outlets in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3 were unavailable on the day of survey.

The facility did not ensure that electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

1. on 02/07/11 at 10:43 AM and at various times throughout the day, the surveyor while accompanied by the Physical Plant Engineer I and Physical Plant Superintendant, observed that electric, clothes dryers located on each patient floor of the Merritt Building were not vented to the exterior of the building with materials that are listed, approved or allowed by the manufacturer ' s installation requirements; i.e. combustible, vinyl exhaust hoses used to vent clothes dryers on 4B, 3B, 3D, etc. others throughout the building

2. on 02/09/11 at 10:08 AM and at various times throughout the day, the surveyor while accompanied by the Physical Plant Engineer II and the clinical staff, observed that electric, clothes dryers located on each patient floor of 500 Vine Street were not vented to the exterior of the building with materials that are listed, approved or allowed by the manufacturer ' s installation requirements; i.e. combustible, vinyl exhaust hoses used to vent clothes dryers on 1st and 2nd floors

The facility did not ensure that where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch is provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.8

On 02/09/11at 9:00 AM, the surveyor observed that the facility had signs posted for the Page Hall that the audible portion of the notification appliances within the building were not functioning and that in the event of fire to listen for an overhead page for instructions but that the visual devices worked. Subsequent interview of the Plant Engineer 3 revealed that he was unaware of the notification and fire watch provisions of the code and that they had not been instituted.