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The facility did not ensure that emergency lighting was being inspected or tested, as required by section # 7.9 of the "Life Safety Code"

1. On 02/01/17 at 10:00 AM, the surveyor was not provided with documentation from the Plant Facility Engineer 2 or the Building Manager to indicate that the battery powered emergency lights throughout the Merritt Building are being inspected monthly or tested annually, as required by section # 7.9 of the "Life Safety Code";

2. On 02/01/17 at 10:00 AM and at other times throughout the day, the surveyor while accompanied by the Plant Facility Engineer 2 and the Building Manager observed that the panel boxes/controls for the old, battery powered emergency light system throughout the Merritt Building were never maintained or removed, as required by section # 4.6.12.4 of the "Life Safety Code".

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

On 01/31/17 - 02/10/17 at 09:00 AM and times throughout the days of survey, the surveyor along with the Plant Facility Engineer 1 and Plant Facility Engineer 2 observed that the smoke barriers throughout the Dutcher Building and the Whiting Forensic building basement and mechanical room had voids and penetrations used for the passage of sprinkler pipes and wires that were not sealed using a UL approved system for fire stopping through a smoke barrier i.e. Non rated backing materials, caulk shrinking and sagging away from voids, sleeves with stuffing and putty removed. The facility had voids and penetrations in most buildings that the facility personal could not identify the UL listed and approved means "system" that was used to seal them.

The facility did not ensure that Emergency and Standby Power Systems was installed and equipped with a remote manual stop as required by NFPA 110 "Standard for Emergency and Standby Power Systems".

On 01/31/17 - 02/10/17 at 9:00 AM and times throughout the survey, the surveyor, while accompanied by the Plant Facility Engineer 1 observed that the newly installed generator at the Blue Hills facility and all other generators for the Connecticut Valley Hospital patient care buildings were not equipped with remote manual stop as required by NFPA 110 2012 edition 5.6.5.6 and NFPA 110 1999 edition 3-5.6.1

The facility did not ensure that a remote annunciator for all patient care buildings were provided, as required by NFPA 99,"Health Care Facilities".
On 01/31/17 - 02/10/17 at 9:00 AM and times throughout the survey, the surveyor, while accompanied by the Plant Facility Engineer 1 observed that a remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel and a common alarm in an area that is observable by all staff, as required by section #'s 6.4.1.1.17, 6.4.1.1.17.1 & 6.4.1.1.17.5; i.e. for the following buildings Battel, Blue Hills, Woodward, Dutcher, Whiting


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On 02/01/17 at 9:40 AM, the surveyor, while accompanied by the Plant Facility Engineer 2 and the Building Manager for the Merritt Builing observed that the newly installed generator lacked an remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel, as required by section #'s 6.4.1.1.17 & 6.4.1.1.17.5; i.e. annunciator panel for new generator that serves equipment branch has been installed in basement electrical room-behind locked door.

The facility did not ensure that the receptacles or the cover plates for the electrical receptacles supplied from the life safety and equipment branches have a distinctive color or marking so as to be readily identifiable, as required by the "Life Safety Code".

On 02/01/17 at 9:30 AM and at other times throughout the day, the surveyor while accompanied by the Plant Facility Engineer 2 and the Building Manager observed that the receptacles or the cover plates for the electrical receptacles supplied from the life safety and equipment branches in the Merritt Building have a distinctive color or marking, as required by section #'s 6.4.2.2.6.2, 6.5.2.2.4.2 & 6.6.2.2.3.2 of NFPA 99, "Healthcare Facilities Code"; i.e. a new (additional) generator set has been installed that serves the equipment branch of essential power-affected receptacles still plain in color-not addressed.