HospitalInspections.org

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Based on observations and interviews, the facility failed to ensure that corridors were separated from all other areas, including patient areas, by walls with at least a one-half (1/2) hour fire resistance rating in areas that lack complete sprinkler protection.

Findings:

On 02/25/15 at 11:22AM, an unsealed cable penetration was found in a corridor wall (vicinity of Room 946) on the 9th Floor of the Main Building.

On 02/25/15 at 2:05PM, an approximately three (3) inch by five (5) inch hole was noted in a corridor wall on the 6th Floor of the Main Building (vicinity of Rooms 602 and 603).

On 02/26/15 at 8:18AM, an unsealed cable penetration was noted in a 5th Floor Main Building corridor wall (vicinity of Room 500).

On 02/26/15 at 8:28AM, an approximately three (3) inch by four (4) inch hole was noted in a corridor wall on the 5th Floor of the Main Building (vicinity of the Storage Closet across from Room 505).

On 02/26/15 at 9:00AM, a partially sealed duct penetration (the top portion of the duct was not sealed) was noted in a corridor wall on the 4th Floor of the Main Building (vicinity of Suite 400 - Staff Offices).

On 02/25/15 at 11:15AM, an approximately eight (8) inch by eight (8) inch hole was noted in a corridor wall on the 2nd Floor of the Main Building (vicinity of the Room M2007 Office).

On 02/27/15 a 1st Floor Main Building Electrical Room (vicinity of the Adult PACU {Post Anesthesia Care Unit} and Adult Operating Room Holding) had an unsealed conduit penetration and the top-of-wall assembly of the corridor-facing wall was not sealed. It was also noted that this room lacked sprinkler protection and would not meet the listed NFPA 13 exception to having sprinkler protection because the room is not enclosed in at least a two (2) hour fire barrier.

As per concurrent interviews with the facility's Director of Engineering, all of the penetrations will be sealed with approved firestopping systems as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.6.1


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Based on observations and interviews, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 18.3.6.3.2 requires that corridor doors in New Health Care Occupancies be provided with a means suitable for keeping the door closed that is acceptable to the Authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). For Facility Building Plans that were approved or a Building Permit that was issued or construction started after March 13, 2003, the building or addition must be surveyed under the 2000 New Health Care Occupancy Chapter. Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings:

On the morning of 02/26/15, the inactive leaves to a set of double doors to Room 263A Radiology Outpatient Reception, Room 263C Radiology Inpatient Reception, Room 242 CAT Scan #1, and the Storage Closet (near the Elevator Lobby in Radiology) on the 2nd Floor of the Main Building were all found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire.

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

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 18.3.6.3.2


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Based on observations and staff interviews, the facility failed to ensure that in smoke compartments that are not fully protected by sprinklers, that vision panels, walls or doors were fixed window assemblies in approved frames. These windows and frames would need to have at least a one-half (1/2) hour fire resistance rating.

Findings:

On 02/25/15 at 12:10PM, three (3) glass panels (each of which were approximately thirty-two {32} inches by thirty-six {36} inches) were noted in a wall that separates the Satellite Pharmacy Room from the corridor on the 7th Floor of the Main Building. These glass panels did not appear that have a fire resistance rating (e.g., were not constructed of wired glass or rated glass). As per concurrent interview with the facility's Director of Engineering, he will notify facility Administration concerning this condition.

On the afternoon of 02/25/15, a wall constructed of non-fire resistance rated glass was noted to separate a Medication Room (Room 631) from the corridor on the 6 North Unit in the Main Building. The smoke compartment in this area is not provided with complete sprinkler protection.

On 02/26/15 at 8:32AM, a wall constructed of non-fire resistance rated glass (e.g., tempered safety glass) was noted to separate a Medication Room (near the Nurses' Station) from the corridor in the 5 North Unit in the Main Building. The smoke compartment in this area is not provided with complete sprinkler protection.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.6.2.3, 19.3.6.2.8


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Based on observation and interview, the facility failed to ensure that all vertical penetrations of fire barriers were enclosed with construction having at least a two (2) hour fire resistance rating.

Findings:

On 02/26/15 at 8:48AM, a partially sealed vertical plumbing penetration was noted in a fire resistance rated floor / ceiling assembly in Room 417 Clean Utility on the 4th Floor of the Main Building.

On 02/26/15 at 8:52AM, a partially sealed vertical plumbing penetration was noted in a fire resistance rated floor / ceiling assembly in the corridor near Room 402 on the 4th Floor of the Main Building.

On 02/27/15 at 9:40AM, an unsealed vertical plumbing penetration was noted in the Main Building Ground Floor Central Sterile Area (old Ethylene Oxide Sterilization System Mechanical Room).

On 02/27/15 at 11:05AM, numerous unsealed conduit penetrations were noted in enclosure walls of the North Soiled Linen Chute Shaft at the Ground Floor Level of the Main Building.

On 02/27/15 at 9:49AM, two (2) partially sealed vertical plumbing penetrations were noted in a floor / ceiling assembly in the 1st Floor Tower Building "Au Bon Pain" Main Storage Room.

As per concurrent interviews with the facility's Director of Engineering, he will have these penetrations completely sealed as soon as possible.

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


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Based on observations and interviews during the survey, the facility failed to ensure that means of egress were properly marked.

Findings:

On 02/27/15 at 10:22AM, two (2) of the Exit Access Doors (which were identified by posted Exit directional signage) from the 3rd Floor Surgical Suite in the Tower Building were found to be improperly marked with "NO EXIT" signage mounted directly to both of these doors. Signs that could confuse building occupants as to whether or not a door is an Exit could potentially endanger their lives in the event of a fire or other emergency.

As per concurrent interview with the Director of Engineering, the "NO EXIT" signage should not be on these Exit Access Doors and will be removed immediately.

On 02/27/15 at 2:33PM, an Exit Access Door in a Tower Building 6th Floor corridor (near Nurses' Station T 640) was found to be improperly marked with "THIS IS NOT AN EXIT" signage.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.2.10.1, 7.10


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Based on observations and interviews, the facility did not ensure that existing smoke barrier walls were constructed to have at least a one-half (1/2) hour fire resistance rating and that smoke dampers were provided in duct penetrations of smoke barriers in smoke compartments that are not protected throughout by an approved supervised Automatic Sprinkler System.

Findings:

On 02/25/15 at 12:17PM, an approximately eight (8) inch by eight (8) inch hole was noted on one (1) side of a 7th Floor smoke barrier wall (in the Main Building vicinity of Room 765).

On 02/25/15 at 12:36PM, a fire / smoke damper penetration of one (1) of the fire barrier walls on the 7th Floor of the Main Building (vicinity of Echocardiography Procedure Room 719) was found to have been improperly sealed with firestopping. Firestopping, when exposed to the heat of a fire, can expand and crush the duct, thus hampering the damper from operating properly.

On 02/25/15 at 1:55PM, two (2) duct penetrations of a 6th Floor smoke barrier wall in the Main Building (vicinity of Room 684 Doctor's Office) lacked required smoke dampers. The smoke compartment in this Unit is not provided with complete sprinkler protection so all duct penetrations of smoke barriers would be required to be provided with approved smoke dampers.

On 02/25/15 at 2:12PM, a duct penetration containing a fire / smoke damper of a Main Building 6th Floor smoke barrier wall (in the 6 South Unit near Exit Stair "B") was found to have been improperly sealed with firestopping. Firestopping, when exposed to the heat of a fire, can expand and crush the duct, thus hampering the damper from operating properly.

On 02/26/15 at 8:39AM, a duct penetration containing a fire / smoke damper of a Main Building 4th Floor smoke barrier wall (above cross-corridor doors near Toilet Room MH-485) was found to have been improperly sealed with firestopping. Firestopping when exposed to the heat of a fire can expand and crush the duct, thus hampering the damper from operating properly.

On 02/26/15 at 9:13AM, four (4) unsealed cable penetrations were noted in a Main Building 3rd Floor smoke barrier wall (vicinity of Room 306).

As per concurrent interviews with the facility's Director of Engineering, all of the penetrations will be sealed with approved firestopping systems as soon as possible.

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


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Based on observations and staff interview during the survey, the facility failed to ensure that: a) Hazardous Storage Rooms that were in New Health Care Occupancies were provided with automatic sprinkler protection enclosed in at least one (1) hour fire resistance rated construction or, if less than one hundred (100) square feet in size, with smoke resistant partitions, and b) all hazardous areas that lack complete automatic sprinkler protection were separated from other spaces by at least one (1) hour fire resistance rated construction and self-closing doors.

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

a) On 02/25/15 at 12:22PM, an unsealed conduit penetration was noted in a wall of a Main Building 7th Floor Patient Bedroom that had been converted into a Storage Room (Room 761). In addition, a fire / smoke damper penetration of one (1) of the fire barrier enclosure walls in this room was found to have been improperly sealed with firestopping. Firestopping, when exposed to the heat of a fire, can expand and crush the duct, thus hampering the damper from operating properly.

As per concurrent interview with the facility's Director of Engineering, he will have the penetration sealed immediately and will have the firestopping removed from around the fire / smoke damper and then have it resealed using approved materials.

On 02/26/15 at 9:08AM, numerous holes were noted in the enclosure walls of a Main Building 3rd Floor Patient Bedroom that had been converted into a Storage Room (Room 308). In addition, this room lacked required sprinkler protection and the door to this room lacked a required self-closing device and must have at least a forty-five (45) minute fire resistance rating.

On 02/27/15 at 10:03AM, a 3rd Floor Main Building Women's Surgical Suite, a former Operating Room (OR #3), that was found to have been converted into a Combustible Storage Area, was found to lack required automatic sprinkler protection, lack a self-closing device on the inactive leaf of the set of doors to this room, lack approved positive latching devices on the inactive leaf, and had an approximately thirty-four (34) inch by thirty-eight (38) inch non-fire resistance rated window in one (1) of the walls to this room. The room is required to have at least a one (1) hour fire resistance rating.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 18.3.2.1, Table 18.3.2.1, 8.4., NFPA 80-1999, Standard for Fire Doors and Fire Windows: 2-4.4.5

b) On 02/26/15 at 9:36AM, numerous unsealed and partially sealed plumbing and conduit penetrations as well as several small holes were noted in enclosure walls of the Supply Storage Room in the Women's Surgical Unit on the 3rd Floor of the Main Building. As per concurrent interview with the facility's Director of Engineering, he will have all of the penetrations and holes sealed as soon as possible.

On 02/26/15 at 11:05AM, numerous unsealed and partially sealed cable and conduit penetrations were noted in the enclosure walls of the Supply Storage Room in a combination Storage / Information Technology Equipment Room (Room M2012) the 2nd Floor of the Main Building. In addition, one (1) of the two (2) sets of doors to this room was noted to lack a required self-closing device. As per concurrent interview with the facility's Director of Engineering, he will have all of the penetrations sealed and a self-closer installed on the door as soon as possible.

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


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Based on observations and staff interview, the facility failed to ensure that openings into Exit enclosures were limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

Findings:

On 02/25/15 at 11:00AM, a door from a Main Building Rooftop (10th Floor) Mechanical Equipment Room was found to open directly into Exit Stair "B".

As per concurrent interview with the facility's Director of Engineering, he will notify facility Administration concerning this condition. This facility lacks complete automatic sprinkler protection and therefore would not be eligible to use a Categorical Waiver for this deficiency.

On 02/27/15 at 11:35AM, the Fire Pump Room on the Cellar Level of the Main Building was found to open directly into Exit Stair "C".

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.2.4.2, 7.2.2.1, 7.1.3.2.1 (d)

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Based on observations, record review, and staff interview, the facility's Fire Plan failed to adequately address evacuation of smoke compartments.

Findings:

On 02/25/15 at 12:35PM, it was noted that smoke barrier walls on the 7th Floor of the Main Building were arranged so that Echocardiography Procedure Room 719 was provided with a single door opening into the adjacent smoke compartment. This configuration requires that the rooms be evacuated in the event of a directed evacuation of either smoke compartment. The facility shall either reroute the smoke barriers or address this issue in the facility's Fire Plan.

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

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.7.2.2 (6)


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Based on observations and staff interviews, the facility failed to ensure that automatic sprinkler protection was provided in all required areas.

Findings:

On 02/26/15 at 11:45AM, an Information Technology Closet in the 2nd Floor of the ECC (Emergency & Critical Care) Building was noted to lack required sprinkler protection.

On 02/27/15 at 2:05PM, a Tower Building 10th Floor Elevator Machine Room (constructed circa 2011) was found to lack required automatic sprinkler protection.

On the afternoon of 02/27/15 and the morning of 03/02/15, sprinklers were found to be missing where required in newly constructed (circa 2011) Exit Stairs. For example, the top (10th Floor) Landing of Exit Stair "A" in the Tower Building and the Ground Floor Landing of Tower Building Exit Stair "C" were found to lack required sprinkler protection.

On the afternoon of 02/27/15 and the morning of 03/02/15, Electrical Rooms (e.g., Electrical Rooms T691, T699, T591, T199B, T199C) in numerous areas of the Tower Building (constructed circa 2011) were found to lack required sprinkler protection and were enclosed in only one (1) hour fire resistance rated construction and therefore would not be eligible to use the NFPA 13-1999 exception to 5-13.11 which permits sprinklers to be omitted in Electrical Rooms that are enclosed by at least two (2) hour fire resistance rated barriers.

On 03/02/15 at 9:15AM, the 1st Floor Main Building Room MH 172 Perioperative Patient Care Services Administrative Office Suite was found to lack required sprinkler protection. This Suite of rooms is located in a smoke compartment that underwent a significant renovation in 2011 and all rooms and spaces within that smoke compartment were supposed to have been provided with automatic sprinkler protection at the time of the renovation project.

On 03/02/15 at 9:45AM, the 1st Floor Tower Building Combination Electrical Room / Storage Room (in the "Au Bon Pain" Suite) was found to lack required sprinkler protection.

On 03/02/15 at 9:55AM, the 1st Floor Tower Building "Au Bon Pain" Elevator Machine Room was found to lack required sprinkler protection.

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

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 18.3.5.1, 19.3.5.1, 19.1.6.1, 9.7.1., NFPA 13-1999 Standard for the Installation of Sprinkler Systems: 5-1.1, 5-13.3.2, 5-13.6, 5-13.11


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Based on observations, record reviews and staff interview, the facility failed to ensure that all fire sprinklers and associated components were maintained in good repair, properly installed, and / or maintained free of foreign material.

The findings include, but are not limited, to the following:

On 02/25/15 at 11:38AM, two (2) concealed sprinklers in Main Building 8 North Unit (vicinity of Room MH-8C09 Electrical / Utility Area) were noted to be missing escutcheon cover plates.

On 02/25/15 at 12:26PM, a concealed sprinkler in Main Building 7th Floor (vicinity of Room MH-7C10 Lobby Area) was noted to be missing an escutcheon cover plate.

On 02/25/15 at 1:57AM, a Tower Building sprinkler control valve on the 6th Floor (vicinity of Mechanical / Electrical Room 660) was noted to be missing required signage that would identify the specific areas this control valve serves.

On 02/26/15 at 9:40AM, a concealed sprinkler in the On-Call Addition Building 3rd Floor (vicinity of the On-Call Staff Sleeping Suite) was noted to be missing an escutcheon cover plate.

On the morning of 02/26/15, an Information Technology Closet on the 2nd Floor of the ECC (Emergency & Critical Care) Building was found to lack required sprinkler protection.

On 02/27/15 at 9:36AM, the Tower Building Ground Floor Central Sterile Clean Pack Area was noted to have both concealed sprinklers and upright sprinklers installed within the same room. The installation of two (2) different types of sprinklers, that may have different operating characteristics, in the same room may not meet the NFPA 13 Requirement that sprinklers be positioned and located so as to provide satisfactory performance with respect to activation time and distribution.

On 02/27/15 at 11:18AM in the Tower Building Ground Floor Carpentry Workshop, Pendant Sprinklers were noted to be improperly installed in the upright position. It was also noted that at least two (2) of these sprinklers had paint on them (sprinklers must be kept free of foreign materials) and that concealed sprinklers were also installed in this room. The installation of different types of sprinklers, that may have different operating characteristics, in the same room may not meet the NFPA 13 Requirement that sprinklers be positioned and located so as to provide satisfactory performance with respect to activation time and distribution.

On 02/27/15 at 12:42PM, two (2) sprinklers in the Food Service Building Ground Floor Cafeteria were noted to have paint on them (sprinklers must be kept free of foreign materials).

On 03/02/15 at 9:42AM, a concealed sprinkler in the 1st Floor Tower Building "Au Bon Pain" Storage Room was noted to be missing its escutcheon cover plate.

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

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-1, Table 2-1


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Based on observations and staff interviews, the facility failed to ensure that portable fire extinguishers were installed in accordance with the Requirements found in NFPA 10, Standard for Portable Fire Extinguishers.

Findings:

On 02/26/15 at 12:03PM, a fire extinguisher that was stored in a recessed cabinet in a wall of the 2nd Floor of the ECC (Emergency & Critical Care) Building (near the Nurses' Station in the Cardiac Care Unit) was noted to lack a required identification sign. When the physical location of a portable fire extinguisher is not readily visible, another form of location identification (e.g., signage) is required.

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

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.5.6, 9.7.4.1, NFPA 10-1998 Standard for Portable Fire Extinguishers: 1-6.10, 1-6.3, 1-6.6


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Based on observations and staff interviews, the facility did not ensure that: a) electrical fixtures in Oxygen Storage Locations were mounted at least sixty (60) inches above the finished floor as a precaution against their physical damage, and b) Bulk Oxygen Systems were not installed less than at least fifty (50) feet from combustible structures. This System was installed in 2011.

Findings:

a) On 02/27/15 at 8:40AM, an electrical light switch in a Compressed Medical Gas (e.g., Nitrogen, Helium, Medical Air) Cylinder Storage Room on the 1st Floor of the Main Building (near Operating Room #2) was installed at a height of forty-seven (47) inches above the floor.

On 02/27/15 at 12:14PM, three (3) electrical light switches, one (1) of which was visibly damaged (the toggle switch was broken off), in a Main Building Ground Floor "Empty Cylinder" Storage Room were installed at a height only approximately forty-eight (48) inches above the floor.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken as soon as possible.

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

b) On 03/02/15 at 2:43PM, a combustible structure (the Modular Building housing the facility's EMS {Emergency Medical Services} Office) was located less than fifty (50) feet (approximately forty {40} feet) from the Bulk Oxygen System. The New York State Department of Health had issued a Time-Limited Waiver in which the Modular Building was supposed to be removed. This Time-Limited Waiver had expired on 12/31/14.

As per concurrent interviews with the facility's Safety Officer and the Director of Engineering, the facility is actively working on a plan to remove this Modular Building.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 12-3.4, 4-3.1.1.2 (b) (1), NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites


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1. Based on observations and staff interview, the facility failed to ensure that at least a one (1) hour fire barrier was maintained between occupied areas and areas under construction.

Findings:

On 02/26/15 at 9:23AM, numerous unsealed cable, conduit, plumbing penetrations and an unsealed duct penetration were noted in the wall that separates a Main Building 3rd Floor Exit Access Corridor from an area under construction (the old Locker Room Area located near Exit Stair "A").

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

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.7.9.1, 19.7.9.2, 7.1.10.1, 4.6.10, NFPA 241, Standard for Safeguarding Construction, Alteration, and Demolition Operations


2. Based on observation and staff interview, the facility failed to ensure that the integrity of fire barriers was maintained.

Findings:

On 02/26/15 at 9:42AM, an unsealed cable penetration was found above the cross-corridor two (2) hour fire resistance rated fire barrier door between the 3rd Floor Women's Surgical Unit of the Main Building and the 3rd Floor On-Call Suite Addition.

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

On 02/26/15 at 12:35PM, two (2) duct penetrations of a two (2) hour fire barrier wall (vicinity of the Freight Elevator on the 2nd Floor of the ECC {Emergency & Critical Care} Building) that were protected by fire dampers were found to have been improperly sealed with firestopping caulk. This firestopping material may expand when exposed to the heat of a fire and could impinge upon (crush) the duct, thus hampering the fire damper from operating properly.

On 02/26/15 at 2:20PM, two (2) duct penetrations of a two (2) hour fire barrier wall between the 1st Floor of the ECC Building and the Cohen's Children's Hospital Building (vicinity of the Room CH-159 Pediatric Ambulatory Surgery Unit) that were protected by fire dampers were found to have been improperly sealed with firestopping caulk. This firestopping material may expand when exposed to the heat of a fire and could impinge upon (crush) the duct, thus hampering the fire damper from operating properly.

On 02/27/15 at 12:20 PM, Dutch Doors in a one (1) hour fire resistance rated fire barrier in the Main Building Ground Floor Mail Room were noted to lack required self-closing devices.

On 02/27/15 at 2:20PM, an approximately two (2) inch by two (2) inch hole was noted in a one (1) hour fire barrier wall that encloses the 10th Floor Tower Building Electrical Room T1091 (It was also noted that this room was recently constructed (approximately 2011), lacks sprinkler protection, and is only enclosed in a one (1) hour fire barrier rather than a two (2) hour fire barrier.

On 03/02/15 at 9:03AM, a duct containing a fire damper that penetrated a two (2) hour fire barrier wall that served a 1st Floor Exit Passageway that served Stair "C" in the Main Building (above the cross-corridor doors vicinity of the Women's Service Guild wall placard) was found to be sealed with firestopping caulk. This material can expand when exposed to the heat of a fire, crushing the duct and hampering the operation of the fire damper.

On 03/02/15 at 9:50AM, an unsealed conduit penetration was noted in the one (1) hour fire barrier wall of the 1st Floor Tower Building "Au Bon Pain" Elevator Machine Room. In addition, an approximately three (3) inch by six (6) inch hole was noted on one (1) side of the fire barrier wall.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.1.1.4.1, 8.2

3. Based on observations and staff interviews, the facility failed to ensure that Exits in Existing Business Occupancy Buildings were continuously maintained free of all impediments or obstructions to full and instant use in case of fire or other emergency.

Findings:

On 02/26/15 at 10:35AM, two (2) thirty-two (32) gallon capacity garbage cans were found to be improperly stored on the 4th Floor Landing of Exit Stair "B" in the Oncology Building.

On 02/26/15 at 10:49AM, a thirty-two (32) gallon capacity garbage can and a floor buffing machine were found to be improperly stored on the 3rd Floor Landing of Exit Stair "B" in the Oncology Building.

On 02/26/15 at 10:50AM, a thirty-two (32) gallon capacity garbage can was found to be improperly stored on the 2nd Floor Landing of Exit Stair "B" in the Oncology Building.

On 02/27/15 at 11:34AM, paint cans, assorted supplies, a mop bucket, and a pair of work boots were found to be stored underneath Exit Stair "C" on the Cellar Level of the Main Building.

As per concurrent interviews with the facility's Director of Engineering, these materials should not be kept in Exits and will be removed immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 39.2.1.1, 7.1.10.1

4. Based on observations and interviews, the facility failed to ensure that Exit Stairs that continue beyond the level of Exit discharge were interrupted at the level of discharge by partitions, doors, or other effective means.

Findings:

On 02/26/15 at 1:34PM, Main Building Exit Stair "B" was found to continue more than one-half (1/2) story beyond the floor of Exit discharge (1st Floor) and was not interrupted at the level of discharge by a partition, door, or other effective physical barrier. As per concurrent interview with the facility's Director of Engineering, he will notify facility Administration of this issue.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.2.7, 7.7.3

5. Based on observations, record review, and staff interviews, the facility failed to ensure that any Patient Care Non-Sleeping Patient Suites were provided with at least one (1) Exit Access Door that led directly to a corridor. The facility would not be eligible to apply the CMS (Centers for Medicare & Medicaid Services) Categorical Waiver for Suites for this Deficiency.

Findings:

On 02/27/15 at 8:25AM, observations and record review (e.g., Floor Plan) revealed that not all Patient Care Non-Sleeping Patient Suites were provided with at least one (1) Exit Access Door that led directly to a corridor. Reference is made to 1st Floor Operating Room Suite "C". The only Exit Access Doors from this Suite are into adjacent Suites (i.e., Operating Room Suite "D" and Operating Room Suite "B") rather than having at least one (1) door that opens into an Exit Access Corridor.

As per concurrent interview with the facility's Director of Engineer, he will notify facility Administration of this issue.


42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.2.51, 19.2.5.3, NFPA 101-2012 Life Safety Code: 19.2.5.7.3.2

6. Based on observations and staff interviews, the facility failed to ensure that recently constructed Operating Rooms on the 3rd Floor of the Tower Building were provided with required battery-powered emergency task lighting.

Findings:

On 02/27/15 at 10:15AM, Operating Room #3 on the 3rd Floor of the Tower Building was noted to lack required battery-powered emergency task lighting.

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

42 CFR 482.41 (b), NFPA 99-1999 Standard for Health Care Facilities: 3-3.2.1.2 (a) (5) (e)

7. Based on observations and staff interview, the facility did not ensure that all Exit Stairs were enclosed in at least one (1) hour fire resistance rated construction.

Findings:

On 02/27/15 at 10:50AM, in the Main Building Ground Floor, Exit Stair "B" was found to be open to the corridor (i.e., it was not enclosed at this Level). It was also noted that the Ground Floor of this building lacks complete sprinkler protection, that this corridor would not meet the requirements to be considered an Exit Passageway, and that Hazardous Storage Areas and other non-normally occupied spaces (e.g., the Primary and Secondary Fire Alarm Control Panel Room) open directly into this corridor.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 39.3.1.1, 8.2.5

8. Based on observations and staff interview, the facility did not ensure that Hazardous Areas in Existing Business Occupancy Areas were in compliance with all applicable NFPA 101, Life Safety Code Requirements.

Findings:

On 02/27/15 at 10:52AM, the door to the Main Building Ground Floor Emergency Equipment Storage Room (vicinity of the Ground Floor Landing of Exit Stair "B") was found to lack a required self-closing device.

On 02/27/15 at 11:03AM, a very heavy build-up of dust was noted on the fusible link of the Main Building Ground Floor Linen Chute Discharge Room. This foreign material can hamper the operation of the fusible link.

On 02/27/15 at 11:09AM, the fusible link on a horizontal sliding fire door (vicinity of the Entrance to the Main Building Ground Floor Carpentry Workshop) was noted to have a foreign substance (e.g., paint) on it. This foreign material can hamper the operation of the fusible link.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 39.3.2.1, 8.4

9. Based on observations and staff interview, the facility did not ensure that Hazardous Areas in New Business Occupancy Areas were in compliance with all applicable NFPA 101, Life Safety Code Requirements.

Findings:

On 02/28/15 at 8:32AM, one (1) of two (2) doors to a newly constructed (in 2014) 1st Floor Tower Building Storage Room ("Vivo Pharmacy" Storage Room T107) lacks a required self-closing device.

On 03/02/15 at 9:45AM, a 1st Floor Tower Building Combination Electrical Room / Storage Room (in the "Au Bon Pain" Suite) was found to lack required sprinkler protection and to lack a working self-closing device on the door.

On 03/02/15 at 9:52AM, a door to the 1st Floor Tower Building "Au Bon Pain" Main Storage Room was noted to be missing a required self-closing device. In addition, a rolling trash cart was noted to be stored against the door, preventing the door from being closed.

On 03/02/15 at 10:13AM, a gap at least one-quarter (1/4) inch wide was found between the meeting edges of a set of doors to the Tower Building Ground Floor Room T020 Logistics Storage Area. The gap between these doors should not be more than one-eighth (1/8) of an inch. An astragal is needed on these doors to eliminate the gap.

On 03/02/15 at 10:15AM, two (2) unsealed duct penetrations and three (3) unsealed plumbing penetrations were noted in a one (1) hour fire barrier wall that encloses the Tower Building Ground Floor Room T022 Biomedical Workshop.

On 03/02/15 at 10:16AM, a gap at least one-quarter (1/4) inch wide was found between the meeting edges of a set of doors to the Tower Building Ground Floor Room T036A POD Pantry Storage Area. The gap between these doors should not be more than one-eighth (1/8) of an inch. An astragal is needed on these doors to eliminate the gap.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 38.3.2.1, 8.4

10. Based on observations and staff interviews, the facility failed to ensure that service openings to ducts containing fire dampers, smoke detectors, and smoke dampers were provided with required identification signage. Service openings in air ducts that contain a fire damper, smoke damper, and smoke detector shall be identified with letters having a minimum height of one-half (1/2) inch to indicate the location of the fire protection device(s) within.

Findings:

On 03/02/15 at 9:53AM, the service opening of two (2) ducts containing fire dampers in the Tower Building 1st Floor "Au Bon Pain" Combination Electrical Equipment / Storage Room were noted to lack required identification signage.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 38.5.5, 9.2.1, NFPA 90A-1998, Standard for the Installation of Air-Conditioning and Ventilating Systems: 2-3.4

11. Based on observations and interviews, the following deficiencies apply to the Pediatrics Outpatient Building located at 410 Lakeville Road, New-Hyde Park, NY 11040. This building was classified as an Existing Business Occupancy according to NFPA 101-2000: Chapter 39.

Findings:

a) The facility failed to provide a means of egress according to LSC 101-2000: Chapter 39. For example, at 10:50AM, on 03/02/15, the two (2) doors to the East Entrance of the facility by Suite 101 have key operated locks on the inner and outer doors to the outside vestibule. Key operated locks are only permitted on one (1) door in the means of egress. In addition the locks do not meet the Requirements found in 7.2.5.1 Exception #2 (see below). It was also noted that one (1) of the two (2) doors in the South Exit was provided with a key operated lock which also did not meet the Requirements of 7.2.5.1 Exception #2.

7.2.1.5.1
Exception #2

On or adjacent to the door, there is a readily visible, durable sign in letters not less than one (1) inch (2.5 cm {two and one-half centimeters}) high on a contrasting background that reads as follows: THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED.

The locking device is of a type that is readily distinguishable as locked.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code 39.2.2.2.2, 39.2.2.2.5, 7.2.1.5.1

b) The facility failed to provide proper protection of Hazardous Areas in the facility. For example, at 11:23AM on 03/02/15, the door to the Medical Records Storage Room in the Adolescent Treatment Area of the Clinic lacked a self-closing device on it.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code 39.2.2.2.1, 7.2.1.8

c) The facility failed to ensure that vertical penetrations were sealed. For example at 11:30AM on 03/02/15, unsealed pipe penetrations were noted in the Fire Pump / HVAC Equipment Room in the Basement of the facility.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42 CFR 482.41 (b), NFPA 101 Life Safety Code 39.3.2.1.8.4

12. Based on observations, staff interviews and record review, the following deficiencies apply to the Center for Advanced Medicine (CFAM) Building located at 450 Lakeville Road, New-Hyde Park, NY 11040. These Deficiencies were noted on the afternoon of 03/02/15.

a) The facility failed to ensure that penetrations of fire barrier walls that contained fire / smoke dampers or fire dampers were properly sealed. Examples include:

i.) A duct containing a smoke / fire damper above the ceiling of Room 1067 was observed to be sealed with fire stopping caulk. This material expands when exposed to the heat of a fire and could crush the duct, hampering the ability of the damper to work properly.

ii) Two ducts containing a smoke / fire damper above the ceiling of Room 1068 were also noted to be sealed with firestopping caulk.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42CFR 482.41 (b), NFPA 101-2000 Life Safety Code 21.3.7.3, 8.3.5, 8.3.6

b) The facility was not provided with a Type 1 Essential Electrical System according to NFPA 99- Health Care Facilities and NFPA 70 - National Electrical Code. Examples are:

i) At 12:10PM, Emergency System - Critical Branch Panel "EPCC-2A" Electrical Room 1083 contained a Circuit labeled "Hot Box Heat Trace City Water". This is an Equipment System Load which is required to be kept separate from Emergency System - Critical Branch Loads.

ii) Emergency System - Life Safety Panel "EPP-1" has a conduit that goes into the same raceway with Emergency System - Critical Panel "PCC2". This was observed at 12:30PM. The Emergency System - Life Safety Branch and Emergency System - Critical Branch wiring are required to be kept separate from each other.

iii) Wiring from Normal Panel "PP1" was noted to be in the same raceway with wiring from Emergency Panel "MDP" in Electrical Room 1067. Normal wiring and emergency wiring must be kept separated.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42CFR 482.41 (b), NFPA 99 - 1999 Standard for Health Care Facilities: 12-3.3.2, 3-4.3

c) The facility failed to ensure that space heaters located in staff Work Areas were provided with heating elements that were capable of producing a maximum temperature of 212 Degrees Farenheit. For example, in Room 1071 at 12:36PM, one (1) of the two (2) portable space heaters was observed and tested to emit heat at a temperature of 218 Degrees Farenheit. As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42CFR 482.41 (b), NFPA 101-2000 Life Safety Code 21.7.8

d) The facility failed to ensure that Hazardous Areas are protected according to NFPA 101-2000: 8.4. For example, at 12:50PM, an empty room (unconstructed shell space that opened into an Exit Stair) around the East Elevator Area of the facility to the upstairs, lacked a self-closing device on the door and also contained an unprotected steel beam.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42CFR 482.41 (b), NFPA 101-2000 Life Safety Code 38.3.2, 8.4

e) The facility failed to properly identify the location of the required fire / smoke barrier. Reference is made to the wall above a cross-corridor doorway in the PACU (Post Anesthesia Care Unit) Area of the Ambulatory Surgery Center was labeled as a fire / smoke barrier but observations, review of the facility's Floor Plan, and concurrent interview with the facility's Safety Officer revealed that it was neither a fire wall, nor a smoke barrier.

NOTE: The facility was advised to check through the labeling of the smoke and fire barriers and educate staff accordingly.

42CFR 482.41 (b), NFPA 101-2000 Life Safety Code 21.3.7.3, 21.7.2.1, 8.3.5, 8.3.6

f) The facility failed to ensure that the required smoke barriers were constructed to have a fire resistance rating of not less than one (1) hour in that unsealed penetrations lacking a listed fire stopping material were noted in the smoke barrier. Examples are:

i) An unsealed wire penetration above the smoke barrier door around the PACU Area.

ii) An unsealed cable penetration above the ceiling in Room 1025.

iii) An unsealed cable penetration above the ceiling of the Waiting Area of the Diagnostic Imaging Center.

iv) An unsealed joint was also observed above the ceiling of the Waiting Area of the Diagnostic Imaging Center.

v) An unsealed hole going through the wall above the ceiling of the Pre-Operation Patient Area.

vi) Another partially sealed wire penetration at above the ceiling of Patient Room 7.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42CFR 482.41 (b), NFPA 101-2000 Life safety Code 21.3.7.3, 8.3

g) The facility failed to ensure the integrity of the two (2) hour fire rated wall in that unprotected steel beams were observed to be part of the two (2) hour rated wall above Examination Room 1203.

42CFR 482.41 (b), NFPA 101-2000 Life Safety Code 21.3.7.3, 8.3

h) The facility failed to ensure that fire extinguishers mounted in recessed cabinets were conspicuously marked with signage that will identify their location. Reference is made to a fire extinguisher installed in a recessed cabinet (vicinity of the Central Receptionist Waiting Area of the facility) which was noted to lack required identification signage.

42CFR 482.41 (b), NFPA 10-1998 Standard for Portable Fire Extinguishers: 1.6.6, 1-6.12

i) The facility failed to ensure that power taps (e.g., "surge protectors") were used in accordance with the provision of the NFPA 70 National Electrical Code. For example, two (2) power taps were found to be serially connected to each other at the Administrative Office Area around Room 2518 at 1:37PM.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42CFR 482.41 (b), NFPA 70 National Electrical Code: 400-9


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Based on observations and record (i.e., Panel Board Schedule) reviews and staff interviews, the facility was not provided with a Type 1 Essential Electrical System that was divided into separate Critical Branch, Life Safety Branch and Equipment Systems in accordance with NFPA 99. In addition, the facility failed to ensure that normal service wiring was separated from emergency service wiring. These deficiencies were noted in existing areas of this facility.

Findings:

On 02/25/15 at 10:36AM, review of the Emergency Power Panel Directory for Panel "ESB-A-12A" in the Main Building Rooftop Penthouse was found to serve Emergency System - Life Safety Branch and Emergency System - Critical Branch Loads. Reference is made to Circuit #8. This Circuit serves both Exit signs and receptacles.

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

On the morning of 02/25/15, Panel Board "EEL-A9A" in the Main Building 9 South Utility Area served Emergency System - Life Safety Branch (e.g., Corridor Lights, Exit Signs, Medical Gas Alarm Panels) Circuits and Emergency System - Critical Branch (e.g., Circuit #11 dedicated receptacle MIS Fiber Optic) functions.

On the morning of 02/25/15, Panel Board "EEL-A8A" in the Main Building 8 South Utility Area served Emergency System - Life Safety Branch (e.g., Exit Signs, Medical Gas Alarm) Circuits and Emergency System - Critical Branch (e.g., Circuit #10 Dedicated receptacle MIS Fiber Optic) functions.

On the afternoon of 02/25/15, Panel Board "ELA7C" in the Main Building 7 South Utility Area had Emergency System - Life Safety Branch (e.g., Corridor Lights, Exit Signs, Medical Gas Alarm) Circuits and Emergency System - Critical Branch (e.g., Nurse Call System, Temporary Receptacle for Computer, Quad Receptacle in Room 742 and the Receptacle at the Nurses' Station) Circuits.

On the afternoon of 02/25/15, Panel Board "EL-A6-C" in the Main Building 6 North Medical Intensive Care Unit Utility Room had an Emergency System - Life Safety Branch (e.g., Medical Gas Alarm) Circuit and Emergency System - Critical Branch (e.g., Nurse Call System, Room Receptacles) Circuits.

On 02/26/15 at 11:41AM a conduit containing a grounding wire was found to connect normal Power Panel "LG2B" to Emergency Power Panel "ELG2B Panel 2" in a 2nd Floor Cardiac Catheterization Unit Equipment Room in the ECC (Emergency & Critical Care) Building. Normal and emergency wiring must be kept separate from each other.

On the morning of 02/27/15, on the 2nd Floor of the Main Building, Panel "APE 2LIDF Sect II" was found to serve Emergency System - Critical Branch (e.g., Operating Room Isolation Panels, Receptacles, Task Lighting) Circuits and an Emergency System - Life Safety Branch (e.g., Medical Gas Alarm) Circuit, Panel "APE 2LIDA" was found to serve Emergency System - Critical Branch (e.g., Receptacles, Task Lighting) Circuits and an Emergency System - Life Safety Branch (e.g., Smoke Damper) Circuit, Panel "ADE2L-REC-C" was found to serve Emergency System - Critical Branch (e.g., Receptacles, Task Lighting, Ice Machine, Pneumatic Tube) Circuits and Emergency System - Life Safety Branch (e.g., Medical Gas Alarms, Exit Lights, Exit Signs) Circuits.

On the morning of 02/27/15, on the 1st Floor of the Main Building, Panel "ELC-1C" (vicinity of Operating Room #10) was found to serve Emergency System - Critical Branch (e.g., Operating Room Task Lighting) Circuits and an Emergency System - Life Safety Branch (e.g., Medical Gas Alarm) Circuit, Panel "APE 2LIDA" was found to serve Emergency System-Critical Branch (e.g., receptacles, task lighting) Circuits and Emergency System - Life Safety Branch (e.g., fire / smoke dampers, corridor lights) Circuits, Panel "APE1-LID" was found to serve Emergency System - Critical Branch (e.g., receptacles, Nurse Call System) Circuits and Emergency System - Life Safety Branch (e.g., Medical Gas Alarm, Exit Signs) Circuits.

On the afternoon of 02/27/15 in the Ground Floor Kitchen of the Food Service Building, Emergency Power Panel "APE1LA" was found to serve Emergency System - Life Safety Branch (e.g., Corridor Lights, Exit Signs) Circuits and Equipment System (e.g., Microwave Oven, Twist Lock Receptacle for Steam Table, Air Curtain) Circuits.

On the morning on 03/02/15, in the 1st Floor Main Building Electrical Panel "ESEAGA" (located in the Electrical Room near the Gift Shop), was found to serve Emergency System - Life Safety Branch (e.g., Stair Lights, Exit Signs, Public Address System) Circuits and Emergency System - Critical Branch (e.g., Corridor Receptacles) Circuits, in the 5th Floor of the Tower Building Panel "WT5S-EPL-CR-2" was found to serve Emergency System - Critical Branch (.e.g., room receptacles) and an Emergency System-Life Safety Branch (e.g., Circuit #62 Security Doors) Circuit, on the 3rd Floor of the Tower Building, Panel "WT3S-EPL-CR-2" was found to serve Emergency System - Critical Branch (e.g., room receptacles) and an Emergency System - Life Safety Branch (e.g., Circuit #62 Security Doors by Stairs) Circuit and 3rd Floor Panel "WT3N-EPL-CR-2" has both Emergency System - Critical Branch (e.g., Room Receptacles) and an Emergency System - Life Safety Branch (e.g., Circuit #55 Corridor Lights) Circuit, and 1st Floor of the Tower Building Panel "W1N-ELL-LS" served Emergency System - Life Safety Branch (e.g., Exit Stair, Exit Discharge and Corridor Lighting, Door Locking Devices), an Equipment System Circuit (e.g., #28 Au Bin Pain Elevator 30 Amp Disconnect), and Emergency System - Critical Branch (e.g., 3rd Floor Telecommunications Baby Monitors) Circuits.

As per concurrent interviews with the facility's Director of Engineering, he will notify facility Administration concerning these conditions.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9


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1. Based on observations and staff interview, the facility failed to ensure that all Panel Board Circuits and Circuit Modifications shall be legibly identified as to purpose or use on a Circuit Directory located on the face or inside of the Panel Doors in accordance with the Requirements of NFPA 70, National Electrical Code.

The findings include, but are not limited to, the following:

On 02/25/15 at 10:34AM, a light fixture in the Main Building Rooftop HVAC Equipment Room had identification labeling that indicated that the fixture was supplied with power from Panel ESB-A-12A Circuit #13 but this fixture was not listed on the Panel Directory for Panel ESB-A-12A.

As per concurrent interview with the facility's Director of Engineering, he will have the Panel Directory updated as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13

2. Based on observations and staff interview during the survey, the facility failed to ensure that electrical wiring was installed in a neat and workman like manner or maintained in good repair and that unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment were provided in accordance with the requirements of NFPA 70, National Electrical Code.

Findings include, but not limited to, the following:

On 02/25/15 at 11:20 AM, a duplex receptacle in a Main Building 9th Floor Corridor (vicinity of the door to Exit Stair "A") was noted to have black scorch marks.

As per concurrent interview with the facility's Director of Engineering, he will have this damaged receptacle replaced as soon as possible.

On 02/26/15 at 11:05 AM, a duplex electrical receptacle in a Combination Storage / Information Technology Equipment Room (Room M2012) the 2nd Floor of the Main Building was noted to lack a required cover plate.

On 02/27/15 at 10:16 AM, a duplex receptacle cover plate ("WT 35 PL-2 #54") in Room T362 Clean Holding on the 3rd Floor of the Tower Building was noted to be cracked. At 10:20AM, a duplex receptacle cover plate in Room T352 Neonatal Stabilization Unit was also noted to be cracked and in need of replacement.

On 02/27/15 at 11:20AM, three (3) unprotected openings (holes) were found in the housing of the Medical Gas Alarm Panel located by the Entrance to the Main Building Ground Floor Carpentry Workshop.

Part of the enclosure housing of Electrical Distribution Panel "EDP-GG-A" in the Ground Floor Switchgear Room in the Main Building was found to be missing.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12

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

Findings:

On 02/26/15 at 1:48PM, temporary wiring was found above the suspended ceilings in ECC1196 Exam #3 in the 1st Floor of the ECC (Emergency & Critical Care) Building.

As per concurrent interview with the facility's Director of Engineering, he will have the temporary wiring removed as soon as possible.

On 02/27/15 at 8:47AM, temporary wiring was found in a Main Building 1st Floor Electrical Closet (vicinity of Operating Room #11).

On 03/02/15 at 9:12AM, temporary wiring was found in the ECC Building 1st Floor Clinical Decision Unit.

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

4. Based on observations and staff interviews, the facility failed to ensure that flexible cords and cables were not used as a substitute for the fixed wiring of a structure.

Findings:

On 02/27/15 at 12:49PM in the Laboratory Unit on the Ground Floor of the Main Building, several extension cords and relocatable power taps (e.g., "surge protectors") were found to be improperly attached in sequence to each other (i.e., "daisy chained").

The facility's Director of Engineering said that he would try to have additional duplex electrical receptacles installed in this area so that electrically powered equipment can be properly connected directly to fixed wiring.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3, 400-8


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Based on observations and interview, the facility did not ensure that Alcohol Based Hand Rub (ABHR) Dispensers were not placed directly above possible ignition sources

Findings:

On 02/27/15 at 10:18AM an ABHR Dispenser was noted mounted on the wall directly above a duplex electrical receptacle in the 3rd Floor Tower Building Room T352 Neonatal Stabilization Unit.

Concurrent interview with the facility's Director of Engineering indicated that he will have this Dispenser relocated as soon as possible.

On 02/27/15 at 12:33PM an ABHR Dispenser was noted mounted on the wall directly above a duplex electrical receptacle in the Ground Floor Food Service Building Kitchen.

Concurrent interview with the facility's Director of Engineering indicated he will have this Dispenser relocated as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 8.4.3

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Based on observations and interviews, the facility failed to ensure that corridors were separated from all other areas, including patient areas, by walls with at least a one-half (1/2) hour fire resistance rating in areas that lack complete sprinkler protection.

Findings:

On 02/25/15 at 11:22AM, an unsealed cable penetration was found in a corridor wall (vicinity of Room 946) on the 9th Floor of the Main Building.

On 02/25/15 at 2:05PM, an approximately three (3) inch by five (5) inch hole was noted in a corridor wall on the 6th Floor of the Main Building (vicinity of Rooms 602 and 603).

On 02/26/15 at 8:18AM, an unsealed cable penetration was noted in a 5th Floor Main Building corridor wall (vicinity of Room 500).

On 02/26/15 at 8:28AM, an approximately three (3) inch by four (4) inch hole was noted in a corridor wall on the 5th Floor of the Main Building (vicinity of the Storage Closet across from Room 505).

On 02/26/15 at 9:00AM, a partially sealed duct penetration (the top portion of the duct was not sealed) was noted in a corridor wall on the 4th Floor of the Main Building (vicinity of Suite 400 - Staff Offices).

On 02/25/15 at 11:15AM, an approximately eight (8) inch by eight (8) inch hole was noted in a corridor wall on the 2nd Floor of the Main Building (vicinity of the Room M2007 Office).

On 02/27/15 a 1st Floor Main Building Electrical Room (vicinity of the Adult PACU {Post Anesthesia Care Unit} and Adult Operating Room Holding) had an unsealed conduit penetration and the top-of-wall assembly of the corridor-facing wall was not sealed. It was also noted that this room lacked sprinkler protection and would not meet the listed NFPA 13 exception to having sprinkler protection because the room is not enclosed in at least a two (2) hour fire barrier.

As per concurrent interviews with the facility's Director of Engineering, all of the penetrations will be sealed with approved firestopping systems as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.6.1


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Based on observations and interviews, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 18.3.6.3.2 requires that corridor doors in New Health Care Occupancies be provided with a means suitable for keeping the door closed that is acceptable to the Authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). For Facility Building Plans that were approved or a Building Permit that was issued or construction started after March 13, 2003, the building or addition must be surveyed under the 2000 New Health Care Occupancy Chapter. Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings:

On the morning of 02/26/15, the inactive leaves to a set of double doors to Room 263A Radiology Outpatient Reception, Room 263C Radiology Inpatient Reception, Room 242 CAT Scan #1, and the Storage Closet (near the Elevator Lobby in Radiology) on the 2nd Floor of the Main Building were all found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire.

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

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 18.3.6.3.2


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Based on observations and staff interviews, the facility failed to ensure that in smoke compartments that are not fully protected by sprinklers, that vision panels, walls or doors were fixed window assemblies in approved frames. These windows and frames would need to have at least a one-half (1/2) hour fire resistance rating.

Findings:

On 02/25/15 at 12:10PM, three (3) glass panels (each of which were approximately thirty-two {32} inches by thirty-six {36} inches) were noted in a wall that separates the Satellite Pharmacy Room from the corridor on the 7th Floor of the Main Building. These glass panels did not appear that have a fire resistance rating (e.g., were not constructed of wired glass or rated glass). As per concurrent interview with the facility's Director of Engineering, he will notify facility Administration concerning this condition.

On the afternoon of 02/25/15, a wall constructed of non-fire resistance rated glass was noted to separate a Medication Room (Room 631) from the corridor on the 6 North Unit in the Main Building. The smoke compartment in this area is not provided with complete sprinkler protection.

On 02/26/15 at 8:32AM, a wall constructed of non-fire resistance rated glass (e.g., tempered safety glass) was noted to separate a Medication Room (near the Nurses' Station) from the corridor in the 5 North Unit in the Main Building. The smoke compartment in this area is not provided with complete sprinkler protection.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.6.2.3, 19.3.6.2.8


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Based on observation and interview, the facility failed to ensure that all vertical penetrations of fire barriers were enclosed with construction having at least a two (2) hour fire resistance rating.

Findings:

On 02/26/15 at 8:48AM, a partially sealed vertical plumbing penetration was noted in a fire resistance rated floor / ceiling assembly in Room 417 Clean Utility on the 4th Floor of the Main Building.

On 02/26/15 at 8:52AM, a partially sealed vertical plumbing penetration was noted in a fire resistance rated floor / ceiling assembly in the corridor near Room 402 on the 4th Floor of the Main Building.

On 02/27/15 at 9:40AM, an unsealed vertical plumbing penetration was noted in the Main Building Ground Floor Central Sterile Area (old Ethylene Oxide Sterilization System Mechanical Room).

On 02/27/15 at 11:05AM, numerous unsealed conduit penetrations were noted in enclosure walls of the North Soiled Linen Chute Shaft at the Ground Floor Level of the Main Building.

On 02/27/15 at 9:49AM, two (2) partially sealed vertical plumbing penetrations were noted in a floor / ceiling assembly in the 1st Floor Tower Building "Au Bon Pain" Main Storage Room.

As per concurrent interviews with the facility's Director of Engineering, he will have these penetrations completely sealed as soon as possible.

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


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Based on observations and interviews during the survey, the facility failed to ensure that means of egress were properly marked.

Findings:

On 02/27/15 at 10:22AM, two (2) of the Exit Access Doors (which were identified by posted Exit directional signage) from the 3rd Floor Surgical Suite in the Tower Building were found to be improperly marked with "NO EXIT" signage mounted directly to both of these doors. Signs that could confuse building occupants as to whether or not a door is an Exit could potentially endanger their lives in the event of a fire or other emergency.

As per concurrent interview with the Director of Engineering, the "NO EXIT" signage should not be on these Exit Access Doors and will be removed immediately.

On 02/27/15 at 2:33PM, an Exit Access Door in a Tower Building 6th Floor corridor (near Nurses' Station T 640) was found to be improperly marked with "THIS IS NOT AN EXIT" signage.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.2.10.1, 7.10


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Based on observations and interviews, the facility did not ensure that existing smoke barrier walls were constructed to have at least a one-half (1/2) hour fire resistance rating and that smoke dampers were provided in duct penetrations of smoke barriers in smoke compartments that are not protected throughout by an approved supervised Automatic Sprinkler System.

Findings:

On 02/25/15 at 12:17PM, an approximately eight (8) inch by eight (8) inch hole was noted on one (1) side of a 7th Floor smoke barrier wall (in the Main Building vicinity of Room 765).

On 02/25/15 at 12:36PM, a fire / smoke damper penetration of one (1) of the fire barrier walls on the 7th Floor of the Main Building (vicinity of Echocardiography Procedure Room 719) was found to have been improperly sealed with firestopping. Firestopping, when exposed to the heat of a fire, can expand and crush the duct, thus hampering the damper from operating properly.

On 02/25/15 at 1:55PM, two (2) duct penetrations of a 6th Floor smoke barrier wall in the Main Building (vicinity of Room 684 Doctor's Office) lacked required smoke dampers. The smoke compartment in this Unit is not provided with complete sprinkler protection so all duct penetrations of smoke barriers would be required to be provided with approved smoke dampers.

On 02/25/15 at 2:12PM, a duct penetration containing a fire / smoke damper of a Main Building 6th Floor smoke barrier wall (in the 6 South Unit near Exit Stair "B") was found to have been improperly sealed with firestopping. Firestopping, when exposed to the heat of a fire, can expand and crush the duct, thus hampering the damper from operating properly.

On 02/26/15 at 8:39AM, a duct penetration containing a fire / smoke damper of a Main Building 4th Floor smoke barrier wall (above cross-corridor doors near Toilet Room MH-485) was found to have been improperly sealed with firestopping. Firestopping when exposed to the heat of a fire can expand and crush the duct, thus hampering the damper from operating properly.

On 02/26/15 at 9:13AM, four (4) unsealed cable penetrations were noted in a Main Building 3rd Floor smoke barrier wall (vicinity of Room 306).

As per concurrent interviews with the facility's Director of Engineering, all of the penetrations will be sealed with approved firestopping systems as soon as possible.

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


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Based on observations and staff interview during the survey, the facility failed to ensure that: a) Hazardous Storage Rooms that were in New Health Care Occupancies were provided with automatic sprinkler protection enclosed in at least one (1) hour fire resistance rated construction or, if less than one hundred (100) square feet in size, with smoke resistant partitions, and b) all hazardous areas that lack complete automatic sprinkler protection were separated from other spaces by at least one (1) hour fire resistance rated construction and self-closing doors.

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

a) On 02/25/15 at 12:22PM, an unsealed conduit penetration was noted in a wall of a Main Building 7th Floor Patient Bedroom that had been converted into a Storage Room (Room 761). In addition, a fire / smoke damper penetration of one (1) of the fire barrier enclosure walls in this room was found to have been improperly sealed with firestopping. Firestopping, when exposed to the heat of a fire, can expand and crush the duct, thus hampering the damper from operating properly.

As per concurrent interview with the facility's Director of Engineering, he will have the penetration sealed immediately and will have the firestopping removed from around the fire / smoke damper and then have it resealed using approved materials.

On 02/26/15 at 9:08AM, numerous holes were noted in the enclosure walls of a Main Building 3rd Floor Patient Bedroom that had been converted into a Storage Room (Room 308). In addition, this room lacked required sprinkler protection and the door to this room lacked a required self-closing device and must have at least a forty-five (45) minute fire resistance rating.

On 02/27/15 at 10:03AM, a 3rd Floor Main Building Women's Surgical Suite, a former Operating Room (OR #3), that was found to have been converted into a Combustible Storage Area, was found to lack required automatic sprinkler protection, lack a self-closing device on the inactive leaf of the set of doors to this room, lack approved positive latching devices on the inactive leaf, and had an approximately thirty-four (34) inch by thirty-eight (38) inch non-fire resistance rated window in one (1) of the walls to this room. The room is required to have at least a one (1) hour fire resistance rating.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 18.3.2.1, Table 18.3.2.1, 8.4., NFPA 80-1999, Standard for Fire Doors and Fire Windows: 2-4.4.5

b) On 02/26/15 at 9:36AM, numerous unsealed and partially sealed plumbing and conduit penetrations as well as several small holes were noted in enclosure walls of the Supply Storage Room in the Women's Surgical Unit on the 3rd Floor of the Main Building. As per concurrent interview with the facility's Director of Engineering, he will have all of the penetrations and holes sealed as soon as possible.

On 02/26/15 at 11:05AM, numerous unsealed and partially sealed cable and conduit penetrations were noted in the enclosure walls of the Supply Storage Room in a combination Storage / Information Technology Equipment Room (Room M2012) the 2nd Floor of the Main Building. In addition, one (1) of the two (2) sets of doors to this room was noted to lack a required self-closing device. As per concurrent interview with the facility's Director of Engineering, he will have all of the penetrations sealed and a self-closer installed on the door as soon as possible.

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


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Based on observations and staff interview, the facility failed to ensure that openings into Exit enclosures were limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

Findings:

On 02/25/15 at 11:00AM, a door from a Main Building Rooftop (10th Floor) Mechanical Equipment Room was found to open directly into Exit Stair "B".

As per concurrent interview with the facility's Director of Engineering, he will notify facility Administration concerning this condition. This facility lacks complete automatic sprinkler protection and therefore would not be eligible to use a Categorical Waiver for this deficiency.

On 02/27/15 at 11:35AM, the Fire Pump Room on the Cellar Level of the Main Building was found to open directly into Exit Stair "C".

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.2.4.2, 7.2.2.1, 7.1.3.2.1 (d)

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Based on observations, record review, and staff interview, the facility's Fire Plan failed to adequately address evacuation of smoke compartments.

Findings:

On 02/25/15 at 12:35PM, it was noted that smoke barrier walls on the 7th Floor of the Main Building were arranged so that Echocardiography Procedure Room 719 was provided with a single door opening into the adjacent smoke compartment. This configuration requires that the rooms be evacuated in the event of a directed evacuation of either smoke compartment. The facility shall either reroute the smoke barriers or address this issue in the facility's Fire Plan.

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

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.7.2.2 (6)


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Based on observations and staff interviews, the facility failed to ensure that automatic sprinkler protection was provided in all required areas.

Findings:

On 02/26/15 at 11:45AM, an Information Technology Closet in the 2nd Floor of the ECC (Emergency & Critical Care) Building was noted to lack required sprinkler protection.

On 02/27/15 at 2:05PM, a Tower Building 10th Floor Elevator Machine Room (constructed circa 2011) was found to lack required automatic sprinkler protection.

On the afternoon of 02/27/15 and the morning of 03/02/15, sprinklers were found to be missing where required in newly constructed (circa 2011) Exit Stairs. For example, the top (10th Floor) Landing of Exit Stair "A" in the Tower Building and the Ground Floor Landing of Tower Building Exit Stair "C" were found to lack required sprinkler protection.

On the afternoon of 02/27/15 and the morning of 03/02/15, Electrical Rooms (e.g., Electrical Rooms T691, T699, T591, T199B, T199C) in numerous areas of the Tower Building (constructed circa 2011) were found to lack required sprinkler protection and were enclosed in only one (1) hour fire resistance rated construction and therefore would not be eligible to use the NFPA 13-1999 exception to 5-13.11 which permits sprinklers to be omitted in Electrical Rooms that are enclosed by at least two (2) hour fire resistance rated barriers.

On 03/02/15 at 9:15AM, the 1st Floor Main Building Room MH 172 Perioperative Patient Care Services Administrative Office Suite was found to lack required sprinkler protection. This Suite of rooms is located in a smoke compartment that underwent a significant renovation in 2011 and all rooms and spaces within that smoke compartment were supposed to have been provided with automatic sprinkler protection at the time of the renovation project.

On 03/02/15 at 9:45AM, the 1st Floor Tower Building Combination Electrical Room / Storage Room (in the "Au Bon Pain" Suite) was found to lack required sprinkler protection.

On 03/02/15 at 9:55AM, the 1st Floor Tower Building "Au Bon Pain" Elevator Machine Room was found to lack required sprinkler protection.

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

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 18.3.5.1, 19.3.5.1, 19.1.6.1, 9.7.1., NFPA 13-1999 Standard for the Installation of Sprinkler Systems: 5-1.1, 5-13.3.2, 5-13.6, 5-13.11


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Based on observations, record reviews and staff interview, the facility failed to ensure that all fire sprinklers and associated components were maintained in good repair, properly installed, and / or maintained free of foreign material.

The findings include, but are not limited, to the following:

On 02/25/15 at 11:38AM, two (2) concealed sprinklers in Main Building 8 North Unit (vicinity of Room MH-8C09 Electrical / Utility Area) were noted to be missing escutcheon cover plates.

On 02/25/15 at 12:26PM, a concealed sprinkler in Main Building 7th Floor (vicinity of Room MH-7C10 Lobby Area) was noted to be missing an escutcheon cover plate.

On 02/25/15 at 1:57AM, a Tower Building sprinkler control valve on the 6th Floor (vicinity of Mechanical / Electrical Room 660) was noted to be missing required signage that would identify the specific areas this control valve serves.

On 02/26/15 at 9:40AM, a concealed sprinkler in the On-Call Addition Building 3rd Floor (vicinity of the On-Call Staff Sleeping Suite) was noted to be missing an escutcheon cover plate.

On the morning of 02/26/15, an Information Technology Closet on the 2nd Floor of the ECC (Emergency & Critical Care) Building was found to lack required sprinkler protection.

On 02/27/15 at 9:36AM, the Tower Building Ground Floor Central Sterile Clean Pack Area was noted to have both concealed sprinklers and upright sprinklers installed within the same room. The installation of two (2) different types of sprinklers, that may have different operating characteristics, in the same room may not meet the NFPA 13 Requirement that sprinklers be positioned and located so as to provide satisfactory performance with respect to activation time and distribution.

On 02/27/15 at 11:18AM in the Tower Building Ground Floor Carpentry Workshop, Pendant Sprinklers were noted to be improperly installed in the upright position. It was also noted that at least two (2) of these sprinklers had paint on them (sprinklers must be kept free of foreign materials) and that concealed sprinklers were also installed in this room. The installation of different types of sprinklers, that may have different operating characteristics, in the same room may not meet the NFPA 13 Requirement that sprinklers be positioned and located so as to provide satisfactory performance with respect to activation time and distribution.

On 02/27/15 at 12:42PM, two (2) sprinklers in the Food Service Building Ground Floor Cafeteria were noted to have paint on them (sprinklers must be kept free of foreign materials).

On 03/02/15 at 9:42AM, a concealed sprinkler in the 1st Floor Tower Building "Au Bon Pain" Storage Room was noted to be missing its escutcheon cover plate.

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

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-1, Table 2-1


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Based on observations and staff interviews, the facility failed to ensure that portable fire extinguishers were installed in accordance with the Requirements found in NFPA 10, Standard for Portable Fire Extinguishers.

Findings:

On 02/26/15 at 12:03PM, a fire extinguisher that was stored in a recessed cabinet in a wall of the 2nd Floor of the ECC (Emergency & Critical Care) Building (near the Nurses' Station in the Cardiac Care Unit) was noted to lack a required identification sign. When the physical location of a portable fire extinguisher is not readily visible, another form of location identification (e.g., signage) is required.

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

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.5.6, 9.7.4.1, NFPA 10-1998 Standard for Portable Fire Extinguishers: 1-6.10, 1-6.3, 1-6.6


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Based on observations and staff interviews, the facility did not ensure that: a) electrical fixtures in Oxygen Storage Locations were mounted at least sixty (60) inches above the finished floor as a precaution against their physical damage, and b) Bulk Oxygen Systems were not installed less than at least fifty (50) feet from combustible structures. This System was installed in 2011.

Findings:

a) On 02/27/15 at 8:40AM, an electrical light switch in a Compressed Medical Gas (e.g., Nitrogen, Helium, Medical Air) Cylinder Storage Room on the 1st Floor of the Main Building (near Operating Room #2) was installed at a height of forty-seven (47) inches above the floor.

On 02/27/15 at 12:14PM, three (3) electrical light switches, one (1) of which was visibly damaged (the toggle switch was broken off), in a Main Building Ground Floor "Empty Cylinder" Storage Room were installed at a height only approximately forty-eight (48) inches above the floor.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken as soon as possible.

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

b) On 03/02/15 at 2:43PM, a combustible structure (the Modular Building housing the facility's EMS {Emergency Medical Services} Office) was located less than fifty (50) feet (approximately forty {40} feet) from the Bulk Oxygen System. The New York State Department of Health had issued a Time-Limited Waiver in which the Modular Building was supposed to be removed. This Time-Limited Waiver had expired on 12/31/14.

As per concurrent interviews with the facility's Safety Officer and the Director of Engineering, the facility is actively working on a plan to remove this Modular Building.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 12-3.4, 4-3.1.1.2 (b) (1), NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites


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1. Based on observations and staff interview, the facility failed to ensure that at least a one (1) hour fire barrier was maintained between occupied areas and areas under construction.

Findings:

On 02/26/15 at 9:23AM, numerous unsealed cable, conduit, plumbing penetrations and an unsealed duct penetration were noted in the wall that separates a Main Building 3rd Floor Exit Access Corridor from an area under construction (the old Locker Room Area located near Exit Stair "A").

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

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.7.9.1, 19.7.9.2, 7.1.10.1, 4.6.10, NFPA 241, Standard for Safeguarding Construction, Alteration, and Demolition Operations


2. Based on observation and staff interview, the facility failed to ensure that the integrity of fire barriers was maintained.

Findings:

On 02/26/15 at 9:42AM, an unsealed cable penetration was found above the cross-corridor two (2) hour fire resistance rated fire barrier door between the 3rd Floor Women's Surgical Unit of the Main Building and the 3rd Floor On-Call Suite Addition.

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

On 02/26/15 at 12:35PM, two (2) duct penetrations of a two (2) hour fire barrier wall (vicinity of the Freight Elevator on the 2nd Floor of the ECC {Emergency & Critical Care} Building) that were protected by fire dampers were found to have been improperly sealed with firestopping caulk. This firestopping material may expand when exposed to the heat of a fire and could impinge upon (crush) the duct, thus hampering the fire damper from operating properly.

On 02/26/15 at 2:20PM, two (2) duct penetrations of a two (2) hour fire barrier wall between the 1st Floor of the ECC Building and the Cohen's Children's Hospital Building (vicinity of the Room CH-159 Pediatric Ambulatory Surgery Unit) that were protected by fire dampers were found to have been improperly sealed with firestopping caulk. This firestopping material may expand when exposed to the heat of a fire and could impinge upon (crush) the duct, thus hampering the fire damper from operating properly.

On 02/27/15 at 12:20 PM, Dutch Doors in a one (1) hour fire resistance rated fire barrier in the Main Building Ground Floor Mail Room were noted to lack required self-closing devices.

On 02/27/15 at 2:20PM, an approximately two (2) inch by two (2) inch hole was noted in a one (1) hour fire barrier wall that encloses the 10th Floor Tower Building Electrical Room T1091 (It was also noted that this room was recently constructed (approximately 2011), lacks sprinkler protection, and is only enclosed in a one (1) hour fire barrier rather than a two (2) hour fire barrier.

On 03/02/15 at 9:03AM, a duct containing a fire damper that penetrated a two (2) hour fire barrier wall that served a 1st Floor Exit Passageway that served Stair "C" in the Main Building (above the cross-corridor doors vicinity of the Women's Service Guild wall placard) was found to be sealed with firestopping caulk. This material can expand when exposed to the heat of a fire, crushing the duct and hampering the operation of the fire damper.

On 03/02/15 at 9:50AM, an unsealed conduit penetration was noted in the one (1) hour fire barrier wall of the 1st Floor Tower Building "Au Bon Pain" Elevator Machine Room. In addition, an approximately three (3) inch by six (6) inch hole was noted on one (1) side of the fire barrier wall.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.1.1.4.1, 8.2

3. Based on observations and staff interviews, the facility failed to ensure that Exits in Existing Business Occupancy Buildings were continuously maintained free of all impediments or obstructions to full and instant use in case of fire or other emergency.

Findings:

On 02/26/15 at 10:35AM, two (2) thirty-two (32) gallon capacity garbage cans were found to be improperly stored on the 4th Floor Landing of Exit Stair "B" in the Oncology Building.

On 02/26/15 at 10:49AM, a thirty-two (32) gallon capacity garbage can and a floor buffing machine were found to be improperly stored on the 3rd Floor Landing of Exit Stair "B" in the Oncology Building.

On 02/26/15 at 10:50AM, a thirty-two (32) gallon capacity garbage can was found to be improperly stored on the 2nd Floor Landing of Exit Stair "B" in the Oncology Building.

On 02/27/15 at 11:34AM, paint cans, assorted supplies, a mop bucket, and a pair of work boots were found to be stored underneath Exit Stair "C" on the Cellar Level of the Main Building.

As per concurrent interviews with the facility's Director of Engineering, these materials should not be kept in Exits and will be removed immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 39.2.1.1, 7.1.10.1

4. Based on observations and interviews, the facility failed to ensure that Exit Stairs that continue beyond the level of Exit discharge were interrupted at the level of discharge by partitions, doors, or other effective means.

Findings:

On 02/26/15 at 1:34PM, Main Building Exit Stair "B" was found to continue more than one-half (1/2) story beyond the floor of Exit discharge (1st Floor) and was not interrupted at the level of discharge by a partition, door, or other effective physical barrier. As per concurrent interview with the facility's Director of Engineering, he will notify facility Administration of this issue.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.2.7, 7.7.3

5. Based on observations, record review, and staff interviews, the facility failed to ensure that any Patient Care Non-Sleeping Patient Suites were provided with at least one (1) Exit Access Door that led directly to a corridor. The facility would not be eligible to apply the CMS (Centers for Medicare & Medicaid Services) Categorical Waiver for Suites for this Deficiency.

Findings:

On 02/27/15 at 8:25AM, observations and record review (e.g., Floor Plan) revealed that not all Patient Care Non-Sleeping Patient Suites were provided with at least one (1) Exit Access Door that led directly to a corridor. Reference is made to 1st Floor Operating Room Suite "C". The only Exit Access Doors from this Suite are into adjacent Suites (i.e., Operating Room Suite "D" and Operating Room Suite "B") rather than having at least one (1) door that opens into an Exit Access Corridor.

As per concurrent interview with the facility's Director of Engineer, he will notify facility Administration of this issue.


42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.2.51, 19.2.5.3, NFPA 101-2012 Life Safety Code: 19.2.5.7.3.2

6. Based on observations and staff interviews, the facility failed to ensure that recently constructed Operating Rooms on the 3rd Floor of the Tower Building were provided with required battery-powered emergency task lighting.

Findings:

On 02/27/15 at 10:15AM, Operating Room #3 on the 3rd Floor of the Tower Building was noted to lack required battery-powered emergency task lighting.

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

42 CFR 482.41 (b), NFPA 99-1999 Standard for Health Care Facilities: 3-3.2.1.2 (a) (5) (e)

7. Based on observations and staff interview, the facility did not ensure that all Exit Stairs were enclosed in at least one (1) hour fire resistance rated construction.

Findings:

On 02/27/15 at 10:50AM, in the Main Building Ground Floor, Exit Stair "B" was found to be open to the corridor (i.e., it was not enclosed at this Level). It was also noted that the Ground Floor of this building lacks complete sprinkler protection, that this corridor would not meet the requirements to be considered an Exit Passageway, and that Hazardous Storage Areas and other non-normally occupied spaces (e.g., the Primary and Secondary Fire Alarm Control Panel Room) open directly into this corridor.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 39.3.1.1, 8.2.5

8. Based on observations and staff interview, the facility did not ensure that Hazardous Areas in Existing Business Occupancy Areas were in compliance with all applicable NFPA 101, Life Safety Code Requirements.

Findings:

On 02/27/15 at 10:52AM, the door to the Main Building Ground Floor Emergency Equipment Storage Room (vicinity of the Ground Floor Landing of Exit Stair "B") was found to lack a required self-closing device.

On 02/27/15 at 11:03AM, a very heavy build-up of dust was noted on the fusible link of the Main Building Ground Floor Linen Chute Discharge Room. This foreign material can hamper the operation of the fusible link.

On 02/27/15 at 11:09AM, the fusible link on a horizontal sliding fire door (vicinity of the Entrance to the Main Building Ground Floor Carpentry Workshop) was noted to have a foreign substance (e.g., paint) on it. This foreign material can hamper the operation of the fusible link.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 39.3.2.1, 8.4

9. Based on observations and staff interview, the facility did not ensure that Hazardous Areas in New Business Occupancy Areas were in compliance with all applicable NFPA 101, Life Safety Code Requirements.

Findings:

On 02/28/15 at 8:32AM, one (1) of two (2) doors to a newly constructed (in 2014) 1st Floor Tower Building Storage Room ("Vivo Pharmacy" Storage Room T107) lacks a required self-closing device.

On 03/02/15 at 9:45AM, a 1st Floor Tower Building Combination Electrical Room / Storage Room (in the "Au Bon Pain" Suite) was found to lack required sprinkler protection and to lack a working self-closing device on the door.

On 03/02/15 at 9:52AM, a door to the 1st Floor Tower Building "Au Bon Pain" Main Storage Room was noted to be missing a required self-closing device. In addition, a rolling trash cart was noted to be stored against the door, preventing the door from being closed.

On 03/02/15 at 10:13AM, a gap at least one-quarter (1/4) inch wide was found between the meeting edges of a set of doors to the Tower Building Ground Floor Room T020 Logistics Storage Area. The gap between these doors should not be more than one-eighth (1/8) of an inch. An astragal is needed on these doors to eliminate the gap.

On 03/02/15 at 10:15AM, two (2) unsealed duct penetrations and three (3) unsealed plumbing penetrations were noted in a one (1) hour fire barrier wall that encloses the Tower Building Ground Floor Room T022 Biomedical Workshop.

On 03/02/15 at 10:16AM, a gap at least one-quarter (1/4) inch wide was found between the meeting edges of a set of doors to the Tower Building Ground Floor Room T036A POD Pantry Storage Area. The gap between these doors should not be more than one-eighth (1/8) of an inch. An astragal is needed on these doors to eliminate the gap.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 38.3.2.1, 8.4

10. Based on observations and staff interviews, the facility failed to ensure that service openings to ducts containing fire dampers, smoke detectors, and smoke dampers were provided with required identification signage. Service openings in air ducts that contain a fire damper, smoke damper, and smoke detector shall be identified with letters having a minimum height of one-half (1/2) inch to indicate the location of the fire protection device(s) within.

Findings:

On 03/02/15 at 9:53AM, the service opening of two (2) ducts containing fire dampers in the Tower Building 1st Floor "Au Bon Pain" Combination Electrical Equipment / Storage Room were noted to lack required identification signage.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 38.5.5, 9.2.1, NFPA 90A-1998, Standard for the Installation of Air-Conditioning and Ventilating Systems: 2-3.4

11. Based on observations and interviews, the following deficiencies apply to the Pediatrics Outpatient Building located at 410 Lakeville Road, New-Hyde Park, NY 11040. This building was classified as an Existing Business Occupancy according to NFPA 101-2000: Chapter 39.

Findings:

a) The facility failed to provide a means of egress according to LSC 101-2000: Chapter 39. For example, at 10:50AM, on 03/02/15, the two (2) doors to the East Entrance of the facility by Suite 101 have key operated locks on the inner and outer doors to the outside vestibule. Key operated locks are only permitted on one (1) door in the means of egress. In addition the locks do not meet the Requirements found in 7.2.5.1 Exception #2 (see below). It was also noted that one (1) of the two (2) doors in the South Exit was provided with a key operated lock which also did not meet the Requirements of 7.2.5.1 Exception #2.

7.2.1.5.1
Exception #2

On or adjacent to the door, there is a readily visible, durable sign in letters not less than one (1) inch (2.5 cm {two and one-half centimeters}) high on a contrasting background that reads as follows: THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED.

The locking device is of a type that is readily distinguishable as locked.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code 39.2.2.2.2, 39.2.2.2.5, 7.2.1.5.1

b) The facility failed to provide proper protection of Hazardous Areas in the facility. For example, at 11:23AM on 03/02/15, the door to the Medical Records Storage Room in the Adolescent Treatment Area of the Clinic lacked a self-closing device on it.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code 39.2.2.2.1, 7.2.1.8

c) The facility failed to ensure that vertical penetrations were sealed. For example at 11:30AM on 03/02/15, unsealed pipe penetrations were noted in the Fire Pump / HVAC Equipment Room in the Basement of the facility.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42 CFR 482.41 (b), NFPA 101 Life Safety Code 39.3.2.1.8.4

12. Based on observations, staff interviews and record review, the following deficiencies apply to the Center for Advanced Medicine (CFAM) Building located at 450 Lakeville Road, New-Hyde Park, NY 11040. These Deficiencies were noted on the afternoon of 03/02/15.

a) The facility failed to ensure that penetrations of fire barrier walls that contained fire / smoke dampers or fire dampers were properly sealed. Examples include:

i.) A duct containing a smoke / fire damper above the ceiling of Room 1067 was observed to be sealed with fire stopping caulk. This material expands when exposed to the heat of a fire and could crush the duct, hampering the ability of the damper to work properly.

ii) Two ducts containing a smoke / fire damper above the ceiling of Room 1068 were also noted to be sealed with firestopping caulk.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42CFR 482.41 (b), NFPA 101-2000 Life Safety Code 21.3.7.3, 8.3.5, 8.3.6

b) The facility was not provided with a Type 1 Essential Electrical System according to NFPA 99- Health Care Facilities and NFPA 70 - National Electrical Code. Examples are:

i) At 12:10PM, Emergency System - Critical Branch Panel "EPCC-2A" Electrical Room 1083 contained a Circuit labeled "Hot Box Heat Trace City Water". This is an Equipment System Load which is required to be kept separate from Emergency System - Critical Branch Loads.

ii) Emergency System - Life Safety Panel "EPP-1" has a conduit that goes into the same raceway with Emergency System - Critical Panel "PCC2". This was observed at 12:30PM. The Emergency System - Life Safety Branch and Emergency System - Critical Branch wiring are required to be kept separate from each other.

iii) Wiring from Normal Panel "PP1" was noted to be in the same raceway with wiring from Emergency Panel "MDP" in Electrical Room 1067. Normal wiring and emergency wiring must be kept separated.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42CFR 482.41 (b), NFPA 99 - 1999 Standard for Health Care Facilities: 12-3.3.2, 3-4.3

c) The facility failed to ensure that space heaters located in staff Work Areas were provided with heating elements that were capable of producing a maximum temperature of 212 Degrees Farenheit. For example, in Room 1071 at 12:36PM, one (1) of the two (2) portable space heaters was observed and tested to emit heat at a temperature of 218 Degrees Farenheit. As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42CFR 482.41 (b), NFPA 101-2000 Life Safety Code 21.7.8

d) The facility failed to ensure that Hazardous Areas are protected according to NFPA 101-2000: 8.4. For example, at 12:50PM, an empty room (unconstructed shell space that opened into an Exit Stair) around the East Elevator Area of the facility to the upstairs, lacked a self-closing device on the door and also contained an unprotected steel beam.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42CFR 482.41 (b), NFPA 101-2000 Life Safety Code 38.3.2, 8.4

e) The facility failed to properly identify the location of the required fire / smoke barrier. Reference is made to the wall above a cross-corridor doorway in the PACU (Post Anesthesia Care Unit) Area of the Ambulatory Surgery Center was labeled as a fire / smoke barrier but observations, review of the facility's Floor Plan, and concurrent interview with the facility's Safety Officer revealed that it was neither a fire wall, nor a smoke barrier.

NOTE: The facility was advised to check through the labeling of the smoke and fire barriers and educate staff accordingly.

42CFR 482.41 (b), NFPA 101-2000 Life Safety Code 21.3.7.3, 21.7.2.1, 8.3.5, 8.3.6

f) The facility failed to ensure that the required smoke barriers were constructed to have a fire resistance rating of not less than one (1) hour in that unsealed penetrations lacking a listed fire stopping material were noted in the smoke barrier. Examples are:

i) An unsealed wire penetration above the smoke barrier door around the PACU Area.

ii) An unsealed cable penetration above the ceiling in Room 1025.

iii) An unsealed cable penetration above the ceiling of the Waiting Area of the Diagnostic Imaging Center.

iv) An unsealed joint was also observed above the ceiling of the Waiting Area of the Diagnostic Imaging Center.

v) An unsealed hole going through the wall above the ceiling of the Pre-Operation Patient Area.

vi) Another partially sealed wire penetration at above the ceiling of Patient Room 7.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42CFR 482.41 (b), NFPA 101-2000 Life safety Code 21.3.7.3, 8.3

g) The facility failed to ensure the integrity of the two (2) hour fire rated wall in that unprotected steel beams were observed to be part of the two (2) hour rated wall above Examination Room 1203.

42CFR 482.41 (b), NFPA 101-2000 Life Safety Code 21.3.7.3, 8.3

h) The facility failed to ensure that fire extinguishers mounted in recessed cabinets were conspicuously marked with signage that will identify their location. Reference is made to a fire extinguisher installed in a recessed cabinet (vicinity of the Central Receptionist Waiting Area of the facility) which was noted to lack required identification signage.

42CFR 482.41 (b), NFPA 10-1998 Standard for Portable Fire Extinguishers: 1.6.6, 1-6.12

i) The facility failed to ensure that power taps (e.g., "surge protectors") were used in accordance with the provision of the NFPA 70 National Electrical Code. For example, two (2) power taps were found to be serially connected to each other at the Administrative Office Area around Room 2518 at 1:37PM.

As per concurrent interview with the facility's Safety Officer, corrective action will be taken immediately.

42CFR 482.41 (b), NFPA 70 National Electrical Code: 400-9


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Based on observations and record (i.e., Panel Board Schedule) reviews and staff interviews, the facility was not provided with a Type 1 Essential Electrical System that was divided into separate Critical Branch, Life Safety Branch and Equipment Systems in accordance with NFPA 99. In addition, the facility failed to ensure that normal service wiring was separated from emergency service wiring. These deficiencies were noted in existing areas of this facility.

Findings:

On 02/25/15 at 10:36AM, review of the Emergency Power Panel Directory for Panel "ESB-A-12A" in the Main Building Rooftop Penthouse was found to serve Emergency System - Life Safety Branch and Emergency System - Critical Branch Loads. Reference is made to Circuit #8. This Circuit serves both Exit signs and receptacles.

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

On the morning of 02/25/15, Panel Board "EEL-A9A" in the Main Building 9 South Utility Area served Emergency System - Life Safety Branch (e.g., Corridor Lights, Exit Signs, Medical Gas Alarm Panels) Circuits and Emergency System - Critical Branch (e.g., Circuit #11 dedicated receptacle MIS Fiber Optic) functions.

On the morning of 02/25/15, Panel Board "EEL-A8A" in the Main Building 8 South Utility Area served Emergency System - Life Safety Branch (e.g., Exit Signs, Medical Gas Alarm) Circuits and Emergency System - Critical Branch (e.g., Circuit #10 Dedicated receptacle MIS Fiber Optic) functions.

On the afternoon of 02/25/15, Panel Board "ELA7C" in the Main Building 7 South Utility Area had Emergency System - Life Safety Branch (e.g., Corridor Lights, Exit Signs, Medical Gas Alarm) Circuits and Emergency System - Critical Branch (e.g., Nurse Call System, Temporary Receptacle for Computer, Quad Receptacle in Room 742 and the Receptacle at the Nurses' Station) Circuits.

On the afternoon of 02/25/15, Panel Board "EL-A6-C" in the Main Building 6 North Medical Intensive Care Unit Utility Room had an Emergency System - Life Safety Branch (e.g., Medical Gas Alarm) Circuit and Emergency System - Critical Branch (e.g., Nurse Call System, Room Receptacles) Circuits.

On 02/26/15 at 11:41AM a conduit containing a grounding wire was found to connect normal Power Panel "LG2B" to Emergency Power Panel "ELG2B Panel 2" in a 2nd Floor Cardiac Catheterization Unit Equipment Room in the ECC (Emergency & Critical Care) Building. Normal and emergency wiring must be kept separate from each other.

On the morning of 02/27/15, on the 2nd Floor of the Main Building, Panel "APE 2LIDF Sect II" was found to serve Emergency System - Critical Branch (e.g., Operating Room Isolation Panels, Receptacles, Task Lighting) Circuits and an Emergency System - Life Safety Branch (e.g., Medical Gas Alarm) Circuit, Panel "APE 2LIDA" was found to serve Emergency System - Critical Branch (e.g., Receptacles, Task Lighting) Circuits and an Emergency System - Life Safety Branch (e.g., Smoke Damper) Circuit, Panel "ADE2L-REC-C" was found to serve Emergency System - Critical Branch (e.g., Receptacles, Task Lighting, Ice Machine, Pneumatic Tube) Circuits and Emergency System - Life Safety Branch (e.g., Medical Gas Alarms, Exit Lights, Exit Signs) Circuits.

On the morning of 02/27/15, on the 1st Floor of the Main Building, Panel "ELC-1C" (vicinity of Operating Room #10) was found to serve Emergency System - Critical Branch (e.g., Operating Room Task Lighting) Circuits and an Emergency System - Life Safety Branch (e.g., Medical Gas Alarm) Circuit, Panel "APE 2LIDA" was found to serve Emergency System-Critical Branch (e.g., receptacles, task lighting) Circuits and Emergency System - Life Safety Branch (e.g., fire / smoke dampers, corridor lights) Circuits, Panel "APE1-LID" was found to serve Emergency System - Critical Branch (e.g., receptacles, Nurse Call System) Circuits and Emergency System - Life Safety Branch (e.g., Medical Gas Alarm, Exit Signs) Circuits.

On the afternoon of 02/27/15 in the Ground Floor Kitchen of the Food Service Building, Emergency Power Panel "APE1LA" was found to serve Emergency System - Life Safety Branch (e.g., Corridor Lights, Exit Signs) Circuits and Equipment System (e.g., Microwave Oven, Twist Lock Receptacle for Steam Table, Air Curtain) Circuits.

On the morning on 03/02/15, in the 1st Floor Main Building Electrical Panel "ESEAGA" (located in the Electrical Room near the Gift Shop), was found to serve Emergency System - Life Safety Branch (e.g., Stair Lights, Exit Signs, Public Address System) Circuits and Emergency System - Critical Branch (e.g., Corridor Receptacles) Circuits, in the 5th Floor of the Tower Building Panel "WT5S-EPL-CR-2" was found to serve Emergency System - Critical Branch (.e.g., room receptacles) and an Emergency System-Life Safety Branch (e.g., Circuit #62 Security Doors) Circuit, on the 3rd Floor of the Tower Building, Panel "WT3S-EPL-CR-2" was found to serve Emergency System - Critical Branch (e.g., room receptacles) and an Emergency System - Life Safety Branch (e.g., Circuit #62 Security Doors by Stairs) Circuit and 3rd Floor Panel "WT3N-EPL-CR-2" has both Emergency System - Critical Branch (e.g., Room Receptacles) and an Emergency System - Life Safety Branch (e.g., Circuit #55 Corridor Lights) Circuit, and 1st Floor of the Tower Building Panel "W1N-ELL-LS" served Emergency System - Life Safety Branch (e.g., Exit Stair, Exit Discharge and Corridor Lighting, Door Locking Devices), an Equipment System Circuit (e.g., #28 Au Bin Pain Elevator 30 Amp Disconnect), and Emergency System - Critical Branch (e.g., 3rd Floor Telecommunications Baby Monitors) Circuits.

As per concurrent interviews with the facility's Director of Engineering, he will notify facility Administration concerning these conditions.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9


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1. Based on observations and staff interview, the facility failed to ensure that all Panel Board Circuits and Circuit Modifications shall be legibly identified as to purpose or use on a Circuit Directory located on the face or inside of the Panel Doors in accordance with the Requirements of NFPA 70, National Electrical Code.

The findings include, but are not limited to, the following:

On 02/25/15 at 10:34AM, a light fixture in the Main Building Rooftop HVAC Equipment Room had identification labeling that indicated that the fixture was supplied with power from Panel ESB-A-12A Circuit #13 but this fixture was not listed on the Panel Directory for Panel ESB-A-12A.

As per concurrent interview with the facility's Director of Engineering, he will have the Panel Directory updated as soon as possible.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13

2. Based on observations and staff interview during the survey, the facility failed to ensure that electrical wiring was installed in a neat and workman like manner or maintained in good repair and that unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment were provided in accordance with the requirements of NFPA 70, National Electrical Code.

Findings include, but not limited to, the following:

On 02/25/15 at 11:20 AM, a duplex receptacle in a Main Building 9th Floor Corridor (vicinity of the door to Exit Stair "A") was noted to have black scorch marks.

As per concurrent interview with the facility's Director of Engineering, he will have this damaged receptacle replaced as soon as possible.

On 02/26/15 at 11:05 AM, a duplex electrical receptacle in a Combination Storage / Information Technology Equipment Room (Room M2012) the 2nd Floor of the Main Building was noted to lack a required cover plate.

On 02/27/15 at 10:16 AM, a duplex receptacle cover plate ("WT 35 PL-2 #54") in Room T362 Clean Holding on the 3rd Floor of the Tower Building was noted to be cracked. At 10:20AM, a duplex receptacle cover plate in Room T352 Neonatal Stabilization Unit was also noted to be cracked and in need of replacement.

On 02/27/15 at 11:20AM, three (3) unprotected openings (holes) were found in the housing of the Medical Gas Alarm Panel located by the Entrance to the Main Building Ground Floor Carpentry Workshop.

Part of the enclosure housing of Electrical Distribution Panel "EDP-GG-A" in the Ground Floor Switchgear Room in the Main Building was found to be missing.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12

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

Findings:

On 02/26/15 at 1:48PM, temporary wiring was found above the suspended ceilings in ECC1196 Exam #3 in the 1st Floor of the ECC (Emergency & Critical Care) Building.

As per concurrent interview with the facility's Director of Engineering, he will have the temporary wiring removed as soon as possible.

On 02/27/15 at 8:47AM, temporary wiring was found in a Main Building 1st Floor Electrical Closet (vicinity of Operating Room #11).

On 03/02/15 at 9:12AM, temporary wiring was found in the ECC Building 1st Floor Clinical Decision Unit.

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

4. Based on observations and staff interviews, the facility failed to ensure that flexible cords and cables were not used as a substitute for the fixed wiring of a structure.

Findings:

On 02/27/15 at 12:49PM in the Laboratory Unit on the Ground Floor of the Main Building, several extension cords and relocatable power taps (e.g., "surge protectors") were found to be improperly attached in sequence to each other (i.e., "daisy chained").

The facility's Director of Engineering said that he would try to have additional duplex electrical receptacles installed in this area so that electrically powered equipment can be properly connected directly to fixed wiring.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3, 400-8


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