HospitalInspections.org

Based on observations during the Life Safety Code survey, it was noted that structural components of the facility were not properly protected from fire. Issues observed include structural steel /steel beams of the building and the beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type I (332).

Findings include:

During the survey of 5th floor Dazain- Maternity suite on 09/10/13 at 11:00 AM, during the observation in the electrical room ( room #80) , it was observed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above were not completely protected with a fire resistive material.

Findings were verified with Director of Engineering and VP of Operations at the time of this observation.

2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1

A. Based on observation and staff interview, the facility failed to safeguard the hazardous area and protect the other areas by providing the required separation and maintaining the fire alarm devices in accordance with NFPA101 2000 Edition.

Findings include:

During the inspection of the fire alarm panel located in the lobby of Bernstein building of Petrie Division on 09/09/13 at approximately 11:00AM, a yellow light was observed indicating "partially disarmed fire alarm device". Upon review of a computer print out of fire alarm trouble and interview of a representative of the fire alarm company on 09/09/13 at approximately 1:00PM, it was revealed that there were six smoke detectors in the mechanical room that were disarmed from the panel.

During the tour of the Mechanical room on 09/09/13 at approximately 2:30PM, it was noted that the mechanical room was approximately 4500 sq. feet. It was also noted that a huge pipe approximately 12 inches wide, passing through the 2 hr rated corridor wall, was cut and left unsealed. This created a penetration in the fire rated corridor wall.

Interview of the Director of Facilities revealed that the facility was in the process of changing the pipes going into the chiller plant on the roof and therefore had disarmed the smoke detectors in that area to prevent false alarms while performing the work.
The facility did not have an Interim Life safety plan that included Fire watch in place while the smoke detectors were disarmed and the construction work was being performed.


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B. Based on observation, the facility did not ensure that hazardous areas are safeguarded from other spaces by doors which are self-closing or automatic-closing, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1.

Findings include:

1. During the tour of the 12th floor Dazain- Storage for the Laboratory area on 09/04/13 at 3:15 PM it was noted that the storage room was seperated from other areas by a one hour fire barrier. The door in this fire barrier was noted being held open by a rope tied to the wall and the handle thus preventing it from latching positively / closing completely.

2. On 09/03/13 at 3:00 PM, during the tour of the Mechanical Equipment room in Bernstein building in the basement, it was noted that the door of the door of the room was not latching positively.

Above finding was shared with the Director of Engineering and Patient Safety staff at the time of observation.

Based on fire safety record reviews and staff interview, it was revealed that: (a) the facility failed to ensure that all staff were fully familiar with the fire safety requirements and procedures for immediate response and emergency evacuation during a fire emergency; and (b) the facility did not ensure that the fire drills were conducted under varying conditions and that planning /evaluation of fire drills were done as per NFPA 101 in its' outpatient building.

Findings include:

A. Review of the Fire safety records and interview of the Director of Facility Operations on 09/04/13 at approximately 11:00AM, it was revealed that the fire alarm system of the Kings Highway Division was changed from a coded Class E system to a non-coded modified Class E fire alarm System. However, upon interview of three (3) nursing staff (on 2 East, 2 North ,and 2 West) and a dietary aide in the kitchen, revealed that the staff were not instructed regarding the audible sound produced upon activation of the pull station. The staff members upon interview regarding the fire alarm system stated that they were instructed to count the bells upon activation of the fire alarm.

In addition, review of the fire drill records for the Kings Highway Division revealed that all the Physicians in the facility did not participate in the fire drills conducted in the facility. Fire drill records for Jan 2012-August 2013 revealed that only 2 Physicians working on 2 West signed as participants in one fire drill conducted on 07/25/ 13 and one Emergency Department physician participated and signed for the fire drill conducted on 05/29/13 in the Emergency Department. This finding was discussed and confirmed with the Director of Fire Safety of the hospital on 09/06/13.


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B. Review of fire drill records on 09/06/13 at 3:30 PM indicated that the hospital did not conduct fire drills in the outpatient setting/Philips Building that include 'simulation of various types of emergency fire conditions' to ensure that each staff has a full and clear understanding of the facility's fire safety plan and how to execute it successfully under the varying conditions.

The fire drills checklist or report did not indicate under what scenario the fire drill was initiated. The log/record presented was in a form of checklist highlighting the points of the drill on which the staff conducting the drill/observer checks off "yes" or "no".

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

Findings were verified with the Directory of Facilities, and Engineering Personal (who is also responsible for Fire Drills) at the time of observation.

Based on record review, and staff interviews, the facility did not ensure that the components comprising the fire alarm system were maintained in a reliable and working condition as per NFPA 101 2000 9.6.1.4 and NFPA 72. Furthermore, the facility did not ensure that all the components of the fire alarm system were tested in accordance with the requirements of NFPA 101 and NFPA 72, National Fire Alarm Code.

The findings include:

1. On 09/05/13 at 11:30 AM , the facility provided a report for 'Valve Tamper Switches and Water Flow devices' dated 06/12/13 that indicated there were issues requiring correction. The facility provided follow up for some of the issues in the report but four issues in the report did not have any corrective action and are still pending.

2. On 09/05/13 at 11:30 AM , during different document review of the fire alarm and the test of its different components, it was noted that the report did not include any information on the testing of the batteries of the fire alarm system as per NFPA 72 (1999) 7-1 and 7-3.2.

Also the various reports did not include all information of different components of fire alarm system as required by code NFPA 72 section 7-5.2.2, figure 7-5.2.2 and Table 7-2.2.

The issue for incomplete/missing information fire alarm report fire was also noted at the Philips Outpatient building.

These findings were verified with Director of Engineering, Assistant Director of Engineering and Vice President of Facilities Operation at the time of observation.

Based on document review and staff interview, it was determined that (a) the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1, and (b) the facility did not ensure that all sprinkler pipes are free of any foreign material and paints as per NFPA 25 and NFPA 13, Standard for the Inspection, Testing and Maintenance of Water Based Fire and Protection System.

Findings include:

A1. On 09/05/13 at 12:00 PM, during documentation review for the sprinkler test, it was noted and verified by Assistant Director of Engineering that there are no documentation or report available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves were conducted. Furthermore, no verification was presented to verify if the gauges were recalibrated or replaced in the past five years.

Similar findings were noted for Philips Outpatient Building.

Note: As per NFPA, there are two activities that are related to obstructions in Chapter 13 that require attention. The first is an investigation that is actually more of an "inspection" as described in Section 13.2.1 that must be conducted every five years. While the sprinkler system is shut down for the purpose of internal valve inspections (See Table 12.1), the flushing connection at the end of one cross main and a single sprinkler at the end of one branch line must be removed and the inside of the piping is then "inspected" for the presence of organic and inorganic material. In Section 13.2.2 a more comprehensive obstruction "investigation" must be conducted when any of the 14 conditions listed in that section are present. This more comprehensive obstruction "investigation" is conducted by internally examining the following four points in a system: system valve, riser, crossmain and, branchline.

A2. On 09/05/13 at 12:30 PM during the review of the report for five year 'Standpipe Hydrostatic test and Flow Test' dated 06/09/11 indicated that the test was performed at test pressure of 100 PSI and for 20 minutes only. As per NFPA 25 1999 section 3-3.2.1
'Hydrostatic tests at not less than 200-psi (13.8-bar) pressure for 2 hours, or at 50 psi (3.4 bar) in excess of the maximum pressure, where maximum pressure is in excess of 150 psi (10.3 bar), shall be conducted every 5 years on dry standpipe systems and dry portions of wet standpipe systems'.

Director of Engineering stated that this test is witnessed by Fire Department of New York (FDNY), however there was no information or verification provided if FDNY approves this to be in compliance with NFPA 25 code or if this test just satisfies FDNY regulations.

A3. On 09/05/13 at 11:30 AM, during review of the main drain test report for the sprinkler it was noted that the report did not have the comparison of the static and residual pressure from the last year's report. Therefore it could not be verified if the differences between the two values were normal for the sprinkler system or as per its hydraulic plate information or not.


B1. During the tour of the facility in the Petrie Division and Philips Outpatient building from 09/3/13 to 09/10/13 between 11:00 AM to 3:30 PM, it was observed that the exposed sprinkler pipes in various parts of the facility exhibited accumulation of lint, dust, and paint specks.

Examples including but not limited to are:

i. Sprinkler head in front of Special Hematology lab (Petrie Division) had dust accumulation on its head.

ii. Sprinkler Cover on maternity floor -5th floor Dazian was noted to be dusty and dirty.

iii. Sprinkler heads in the corridor of Medical suite-11 Linsky had dirty and dusty sprinkler heads.

iv. A sprinkler head opposite the server room on Pediatric floor on 6th Dazian had specks of paint on it.

Note: Section 2-2.1.1* of NFPA 25 states that, "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

Findings were verified with the Director of Engineering and VP of Operations at the time of observation.

Based on observation and document review, the facility failed to ensure that (a) all of the portable fire extinguishers in the are inspected for their 6 years maintenance check as per NFPA 10 4-4.3; (b) portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10); (c) the facility did not ensure that the fire extinguishers are stored in such a manner that they are easily accessible in case of emergency; and (d) fire extinguishers were secured installed on the wall.


Findings include:

A. During document review on 09/06/13 at 03:55 PM, during review of the documentation at Philips Outpatient building, no information was provided for 6 year refill and maintenance test for all the portable fire extinguishers in the facility. On 09/09/13 at 12;30 PM, Director of Facilities from Outpatient Building provided a sheet of tests for fire extinguisher which did not include the information for all the portable extinguishers and this information was not clear.

B. During survey of Petrie Division and Philips Outpatient from 09/03/13 to 09/10/13 between 11:00 AM to 4:00 PM, it was noted that many the fire extinguishers were installed in is such a way that its top most portion was greater than the required 5 ft. (60 inches).

Examples include but are not limited to:

i. Fire extinguisher located by suite 3G in Philips Outpatient suite was noted to be installed at a height greater than 5 ft.

ii. The extinguisher by the rear Exit in the OR suite by the PACU (Petrie Division) was noted installed above 5 ft.


C. During survey of the Petrie Division and Philips Outpatient site from 09/03/13 to 09/10/13 between 11:00 AM to 4:00 PM, it was noted that many the fire extinguishers were blocked by carts and equipment , thus making the portable extinguishers not readily accessible at the time of emergency. Examples include but are not limited to:

i. The fire extinguisher in the corridor of Orange Pod of the Emergency Department was noted to be blocked by carts and a portable computer.

ii. The fire extinguisher in the Maternity suite -5th floor Dazian was noted to be blocked by portable equipment.

Note: Section 1-6.3 of NFPA 10 states that fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

D. During the survey of the generator/mechanical room in basement of Dazian on 09/10/13 at 11:45 AM, a fire extinguisher was noted to be placed on the floor and not securely installed on the wall to avoid the extinguisher being damaged by falling down.

All above findings mentioned in this tag were verified with Director of Engineering, Vice President of Facilities Operation, and staff escorting the surveyor at the time of observation/survey.

Based on documentation review and staff interview, the facility failed to ensure that all fire dampers installed in all buildings at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair and installed in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

1. On 09/05/13 at 11:50 AM, during review of fire/smoke damper assessment of Petrie Campus/Division dated 03/09/11, it was noted that many dampers had deficiencies in the different buildings of the campus. No follow up report or work order was provided to verify that those deficiencies were corrected.

2. During the inspection of the fire and smoke barriers in the facility from 09/03/13 to 09/10/13 between 11:30 AM to 4:00 PM, it was noted that that there were various ducts penetrating through the fire/smoke barrier. These ducts had fire sealant/caulking around it. The ducts were equipped with fire dampers.
NOTE: As per NFPA 90A 3-4.6 Exception: Where fire dampers are installed, proper clearance for expansion shall be maintained. (See 3-4.6.)

Therefore as per the above section, the code requires proper clearance for expansion should be maintained.
Furthermore NFPA 90A section 3-4.6.2* states that "Fire dampers, including their sleeves; smoke dampers; and ceiling dampers shall be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions".

The UL Building Material Directory also does not allow the space to be filled with any material.
Thus facility did not ensure that the ducts with fire dampers do not have their retaining angles sealed with fire caulking or sealant as that compromises the fire damper UL listing as per UL 555.

Findings were verified with the Director of Engineering and VP of Operations at the time of observation.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Furthermore, such arrangement also decreased the width of the exit access corridor from a minimum of at least 4 feet as required by NFPA 101 19.2.3.3.

Findings include:

During the tour of different parts of the facility ( Petrie Division and Philips Outpatient Building) from 09/03/13 to 09/10/13 between 11:00 AM to 4:00 PM, impediments in the path of egress were noted and the corridor width was less than 4 feet.
Examples include but are not limited to the following:
1. On 09/03/13 at 2:00 PM, during a tour of the Medical Unit-11th floor Linsky it was noted in the corridor that a stretcher/bed was parked and thus impeded the path of egress. Furthermore, the presence of the stretcher/bed decreased the width of the corridor.
2. On 09/04/13 at 12:40 PM, during the tour of the Labor and Delivery Suite -4th floor Dazian, it was noted that a IV pumps and other equipments were placed in the exit corridor near room #11.
3. On 09/06/13 at 12:00 PM, during the tour of the Ambulatory Surgical Suite at the Philips Outpatient building it was noted that , near the OR suite outside the mechanical room, there were x-ray equipment and other such items impeding the exit corridor. Furthermore, the equipment was also noted to be blocking the electrical panels.
4. On 09/09/13 at 11:30 AM, during the tour of the Central Sterile Processing Department in the basement-Karpas it was noted that the exit corridor to the clean processing area was cluttered with carts, racks, and other similar equipment.
5. On 09/09/13 between 12:00 PM to 1:00 PM, during the tour of the OR suite in the Petrie Division, various exit corridors were noted having carts, beds/stretchers, and equipment stored in a way that impeded the exit access or decreased the width or the corridor. One such example was seen by the exit corridor near OR #9.
These findings were verified with the Director of Engineering and VP of Hospital Operations at the time of observation..

Based on observation, the facility did not ensure that all trash collection receptacles with capabilities greater than 32 gallons are located in a room protected as a hazardous area when not attended.

Findings include:

On 09/03/13 at 2:00 PM during the tour of the Medical Unit-11th Floor Linsky it was noted that one large garbage container (used to store and transport garbage greater than 32 gallon) was being stored unattended in the alcove near the service elevators.

The VP of Hospital Operations acknowledged that all soiled linen/trash bags/containers, when not attended, should be stored in a room which is enclosed with a minimum of 1 hour fire resistance rated construction.

Findings were verified with the Director of Engineering and VP of Operations at the time of observation.

Based on record review and staff interview, the facility did not ensure that the piped in medical gas system's deficiencies were corrected in a timely manner and as per NFPA 99.

Findings include:

On 09/05/13 at 2:30 PM during the review of the medical gas report of the facility from 'Evergreen Medical Services' dated June 11 2013, it was noted that the report indicated many repair deficiencies, leaks, and flow failures. No follow up report was provided indicating if these deficiencies had been corrected.

Furthermore, in reviewing the past years's medical gas report of October 12/2012, it was noted that more than 85% of the current deficiencies were the same as those that were identified last year.

Therefore, this comparison indicated that facility did not have all issues identified in 2012 corrected in a timely manner to ensure patient safety.


Findings were confirmed with Director of Engineering, Assistant Director of Engineering and Vice President of Facilities Operation at the time of observation.

Based on observation in the different areas of the facility, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls and penetrations made through floors were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6

Findings include:

During the tour of the facility from 09/03/13 to 09/10/13 between 11:00 AM to 4:00 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected for the integrity of smoke barriers. The rated walls of different areas/rooms were also inspected for integrity.

It was noted that the barriers and floors were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes. These penetrations were not completely sealed all around with an approved fire retardant material to prevent passage of smoke from one compartment to the other. The penetrations made through one floor to the other in mechanical/electrical/IT closets were also observed.

Examples, include, but were not limited to:

a. On 09/13/13 at 12:30 PM , during the tour of the Emergency Department, it was noted that the fire/smoke barrier rated wall above the double had unsealed penetrations made by ducts, structural beams/studs, and pipes.

b. On 09/04/13 at 2:45 PM, during the tour of the CPEP area of Emergency Department, it was noted that the smoke barriers had miscellaneous penetrations of the rated wall with improperly sealed ducts and sleeves of wires. A great amount of duct insulation was also observed as not intact and ripped/open/vulnerable to fire conditions.

d. On 09/06/13 at 12:00 PM, during the tour of the Ambulatory Surgical Suite/Center at the Philips outpatient building, some penetrations were noted in the mechanical room made by conduits that were void of fire retardant..

c. On 09/06/13 at 12:15 PM, during the tour of the Ambulatory Surgical Suite/Center at the Philips outpatient building, the soiled utility room was noted having penetrations in the back wall, which was the rated wall as per the floor plan. It was noted that the two side walls of this room (that were also indicated to be one hour wall) did not have a wall extending from slab to slab and thus this room was not a rated room as indicated by the floor plan.

d. On 09/06/13 at 12:30 PM, during the tour of the Ambulatory Surgical Suite/Center at the Philips outpatient building, the fire barrier wall by the stairwell was noted to have penetrations that were not sealed with any fire retardant material

e. On 09/06/13 at 12:30 PM, during the tour of the Ambulatory Surgical Suite/Center at the Philips outpatient building. the smoke barrier wall (as identified by the floor plan) by the patient dressing area had many penetrations that were not sealed with any fire retardant material. Furthermore, the glass smoke door did not have any tag to indicate if it was a rated door.

f. On 09/09/13 at 2:30 PM, during the tour of the Pediatric Floor -6th floor Karpas, it was noted that the one and two hour walls of the IT/electrical closet (near the entrance to the unit) were compromised with penetrations or gaps not properly sealed with fire retardant material.

d. On 09/09/13 at 2:30 PM, during the tour of the Pediatric Floor -6th floor Karpas it was noted that the IT/electrical closet had many conduits/ penetration through the floor going to the electrical/IT room below and the penetration was not sealed with any fire retardant material.

e. On 09/10/13 at 11:30 AM, during the tour of the Maternity Floor -5th floor Dazian it was noted that the electrical closet opposite the nurse's station had penetrations of the rated wall made by conduits. Furthermore, another electrical closet after the soiled utility room had a metal frame on the rated ceiling that did not have any information noted for its rating. Therefore, it could not be verified if the rated ceiling was indeed compliant for an hour rated partition.

All above findings were verified with the Director of Engineering and Vice President for Facilities Operations at the Petrie Division at the time of observation and Director of Facilities at the Philips outpatient building at the time of survey/observation.

Note: Section 8.3.6.1 of NFPA 101 states that:

Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

b. It shall be protected by an approved device that is designed for the specific purpose.

Based on review of the emergency generator testing records and staff interview, the facility failed to ensure that the the two emergency generators installed at the Kings Highway division of the facility were tested and maintained in accordance with NFPA 110.

Findings include:

Review of the testing records of August 16, 2013 on the the two generators ( Cummins and Detroit) on 09/06/13 at approximately 11:30AM, revealed that the there was no documented evidence of testing conducted on 8 of the 9 automatic transfer switches to ensure that the required illumination was provided automatically and promptly in the event of interruption of normal lighting in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

During interview of the Director of Engineering on 09/06/13 at approximately 12:30 PM, it was stated that the transfer test on the transfer switches were conducted by the contractor, but did not document the time taken to transfer power on the testing records.

Based on document review and staff interview, facility did not ensure that the line isolation monitors were maintained in fully operating condition.

Findings include:

On 09/0505/13 at 12;15 PM, during the document review , facility was asked to provide reports for the line isolation monitors. A report dated 06/30/13 from 'PG LifeLink' was provided which indicated that there were "many panels that were non-conforming and the test values were outside established criteria".

A previous report was not provided to compare how long this issue had persisted in the family. Furthermore, no follow-up or corrective action/plan was provided regarding the plan by the facility to fix the issues noted in the report.

These findings were verified with Director of Engineering, Assistant Director of Engineering and Vice President of facilities Operation at the time of observation.

Based on document review and staff interview, it was determined that the facility performs general anesthesia and has emergency generators installed in the facility and thus requires a Type I EES (essential electrical system). The wiring of the electrical system at the panels on patient care floors in the Petrie Division are not in compliance with the code, NFPA 99 3-4, and generators are not divided into three branches.

Findings include:

1. In an interview with Director of Engineering and Vice President of Operation of Hospital Operations on 09/03/13 at 1:30 PM, the VP indicated that the wiring configuration in the facility for the Type I EES is not in compliance with 1999 NFPA 99 3-4.2.2.1. The specific issue involved was that the separation of the generator branches into a life safety, critical, and equipment system was not done for the generators and panels on patient floors were not provided for segregating the three branches. Thus the panels at the main mechanical room/switch gear room/generator has mixed wiring for life safety, critical, and equipment branches in whatever panel is present in the facility.

Document review of the panel and switches on 09/04/13 at 11:00 AM also revealed that the wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System, and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch.

1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.

Note: As per NFPA 99 Section 3-4.2.2.2
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems."
4. Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.


All above findings were verified with Director of Engineering, Vice President of Facilities Operation and engineering/electrical staff escorting the surveyor at the time of observation/survey.

Based on observations during the Life Safety Code survey, it was noted that structural components of the facility were not properly protected from fire. Issues observed include structural steel /steel beams of the building and the beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type I (332).

Findings include:

During the survey of 5th floor Dazain- Maternity suite on 09/10/13 at 11:00 AM, during the observation in the electrical room ( room #80) , it was observed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above were not completely protected with a fire resistive material.

Findings were verified with Director of Engineering and VP of Operations at the time of this observation.

2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1

A. Based on observation and staff interview, the facility failed to safeguard the hazardous area and protect the other areas by providing the required separation and maintaining the fire alarm devices in accordance with NFPA101 2000 Edition.

Findings include:

During the inspection of the fire alarm panel located in the lobby of Bernstein building of Petrie Division on 09/09/13 at approximately 11:00AM, a yellow light was observed indicating "partially disarmed fire alarm device". Upon review of a computer print out of fire alarm trouble and interview of a representative of the fire alarm company on 09/09/13 at approximately 1:00PM, it was revealed that there were six smoke detectors in the mechanical room that were disarmed from the panel.

During the tour of the Mechanical room on 09/09/13 at approximately 2:30PM, it was noted that the mechanical room was approximately 4500 sq. feet. It was also noted that a huge pipe approximately 12 inches wide, passing through the 2 hr rated corridor wall, was cut and left unsealed. This created a penetration in the fire rated corridor wall.

Interview of the Director of Facilities revealed that the facility was in the process of changing the pipes going into the chiller plant on the roof and therefore had disarmed the smoke detectors in that area to prevent false alarms while performing the work.
The facility did not have an Interim Life safety plan that included Fire watch in place while the smoke detectors were disarmed and the construction work was being performed.


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B. Based on observation, the facility did not ensure that hazardous areas are safeguarded from other spaces by doors which are self-closing or automatic-closing, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1.

Findings include:

1. During the tour of the 12th floor Dazain- Storage for the Laboratory area on 09/04/13 at 3:15 PM it was noted that the storage room was seperated from other areas by a one hour fire barrier. The door in this fire barrier was noted being held open by a rope tied to the wall and the handle thus preventing it from latching positively / closing completely.

2. On 09/03/13 at 3:00 PM, during the tour of the Mechanical Equipment room in Bernstein building in the basement, it was noted that the door of the door of the room was not latching positively.

Above finding was shared with the Director of Engineering and Patient Safety staff at the time of observation.

Based on fire safety record reviews and staff interview, it was revealed that: (a) the facility failed to ensure that all staff were fully familiar with the fire safety requirements and procedures for immediate response and emergency evacuation during a fire emergency; and (b) the facility did not ensure that the fire drills were conducted under varying conditions and that planning /evaluation of fire drills were done as per NFPA 101 in its' outpatient building.

Findings include:

A. Review of the Fire safety records and interview of the Director of Facility Operations on 09/04/13 at approximately 11:00AM, it was revealed that the fire alarm system of the Kings Highway Division was changed from a coded Class E system to a non-coded modified Class E fire alarm System. However, upon interview of three (3) nursing staff (on 2 East, 2 North ,and 2 West) and a dietary aide in the kitchen, revealed that the staff were not instructed regarding the audible sound produced upon activation of the pull station. The staff members upon interview regarding the fire alarm system stated that they were instructed to count the bells upon activation of the fire alarm.

In addition, review of the fire drill records for the Kings Highway Division revealed that all the Physicians in the facility did not participate in the fire drills conducted in the facility. Fire drill records for Jan 2012-August 2013 revealed that only 2 Physicians working on 2 West signed as participants in one fire drill conducted on 07/25/ 13 and one Emergency Department physician participated and signed for the fire drill conducted on 05/29/13 in the Emergency Department. This finding was discussed and confirmed with the Director of Fire Safety of the hospital on 09/06/13.


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B. Review of fire drill records on 09/06/13 at 3:30 PM indicated that the hospital did not conduct fire drills in the outpatient setting/Philips Building that include 'simulation of various types of emergency fire conditions' to ensure that each staff has a full and clear understanding of the facility's fire safety plan and how to execute it successfully under the varying conditions.

The fire drills checklist or report did not indicate under what scenario the fire drill was initiated. The log/record presented was in a form of checklist highlighting the points of the drill on which the staff conducting the drill/observer checks off "yes" or "no".

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

Findings were verified with the Directory of Facilities, and Engineering Personal (who is also responsible for Fire Drills) at the time of observation.

Based on record review, and staff interviews, the facility did not ensure that the components comprising the fire alarm system were maintained in a reliable and working condition as per NFPA 101 2000 9.6.1.4 and NFPA 72. Furthermore, the facility did not ensure that all the components of the fire alarm system were tested in accordance with the requirements of NFPA 101 and NFPA 72, National Fire Alarm Code.

The findings include:

1. On 09/05/13 at 11:30 AM , the facility provided a report for 'Valve Tamper Switches and Water Flow devices' dated 06/12/13 that indicated there were issues requiring correction. The facility provided follow up for some of the issues in the report but four issues in the report did not have any corrective action and are still pending.

2. On 09/05/13 at 11:30 AM , during different document review of the fire alarm and the test of its different components, it was noted that the report did not include any information on the testing of the batteries of the fire alarm system as per NFPA 72 (1999) 7-1 and 7-3.2.

Also the various reports did not include all information of different components of fire alarm system as required by code NFPA 72 section 7-5.2.2, figure 7-5.2.2 and Table 7-2.2.

The issue for incomplete/missing information fire alarm report fire was also noted at the Philips Outpatient building.

These findings were verified with Director of Engineering, Assistant Director of Engineering and Vice President of Facilities Operation at the time of observation.

Based on document review and staff interview, it was determined that (a) the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1, and (b) the facility did not ensure that all sprinkler pipes are free of any foreign material and paints as per NFPA 25 and NFPA 13, Standard for the Inspection, Testing and Maintenance of Water Based Fire and Protection System.

Findings include:

A1. On 09/05/13 at 12:00 PM, during documentation review for the sprinkler test, it was noted and verified by Assistant Director of Engineering that there are no documentation or report available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves were conducted. Furthermore, no verification was presented to verify if the gauges were recalibrated or replaced in the past five years.

Similar findings were noted for Philips Outpatient Building.

Note: As per NFPA, there are two activities that are related to obstructions in Chapter 13 that require attention. The first is an investigation that is actually more of an "inspection" as described in Section 13.2.1 that must be conducted every five years. While the sprinkler system is shut down for the purpose of internal valve inspections (See Table 12.1), the flushing connection at the end of one cross main and a single sprinkler at the end of one branch line must be removed and the inside of the piping is then "inspected" for the presence of organic and inorganic material. In Section 13.2.2 a more comprehensive obstruction "investigation" must be conducted when any of the 14 conditions listed in that section are present. This more comprehensive obstruction "investigation" is conducted by internally examining the following four points in a system: system valve, riser, crossmain and, branchline.

A2. On 09/05/13 at 12:30 PM during the review of the report for five year 'Standpipe Hydrostatic test and Flow Test' dated 06/09/11 indicated that the test was performed at test pressure of 100 PSI and for 20 minutes only. As per NFPA 25 1999 section 3-3.2.1
'Hydrostatic tests at not less than 200-psi (13.8-bar) pressure for 2 hours, or at 50 psi (3.4 bar) in excess of the maximum pressure, where maximum pressure is in excess of 150 psi (10.3 bar), shall be conducted every 5 years on dry standpipe systems and dry portions of wet standpipe systems'.

Director of Engineering stated that this test is witnessed by Fire Department of New York (FDNY), however there was no information or verification provided if FDNY approves this to be in compliance with NFPA 25 code or if this test just satisfies FDNY regulations.

A3. On 09/05/13 at 11:30 AM, during review of the main drain test report for the sprinkler it was noted that the report did not have the comparison of the static and residual pressure from the last year's report. Therefore it could not be verified if the differences between the two values were normal for the sprinkler system or as per its hydraulic plate information or not.


B1. During the tour of the facility in the Petrie Division and Philips Outpatient building from 09/3/13 to 09/10/13 between 11:00 AM to 3:30 PM, it was observed that the exposed sprinkler pipes in various parts of the facility exhibited accumulation of lint, dust, and paint specks.

Examples including but not limited to are:

i. Sprinkler head in front of Special Hematology lab (Petrie Division) had dust accumulation on its head.

ii. Sprinkler Cover on maternity floor -5th floor Dazian was noted to be dusty and dirty.

iii. Sprinkler heads in the corridor of Medical suite-11 Linsky had dirty and dusty sprinkler heads.

iv. A sprinkler head opposite the server room on Pediatric floor on 6th Dazian had specks of paint on it.

Note: Section 2-2.1.1* of NFPA 25 states that, "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

Findings were verified with the Director of Engineering and VP of Operations at the time of observation.

Based on observation and document review, the facility failed to ensure that (a) all of the portable fire extinguishers in the are inspected for their 6 years maintenance check as per NFPA 10 4-4.3; (b) portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10); (c) the facility did not ensure that the fire extinguishers are stored in such a manner that they are easily accessible in case of emergency; and (d) fire extinguishers were secured installed on the wall.


Findings include:

A. During document review on 09/06/13 at 03:55 PM, during review of the documentation at Philips Outpatient building, no information was provided for 6 year refill and maintenance test for all the portable fire extinguishers in the facility. On 09/09/13 at 12;30 PM, Director of Facilities from Outpatient Building provided a sheet of tests for fire extinguisher which did not include the information for all the portable extinguishers and this information was not clear.

B. During survey of Petrie Division and Philips Outpatient from 09/03/13 to 09/10/13 between 11:00 AM to 4:00 PM, it was noted that many the fire extinguishers were installed in is such a way that its top most portion was greater than the required 5 ft. (60 inches).

Examples include but are not limited to:

i. Fire extinguisher located by suite 3G in Philips Outpatient suite was noted to be installed at a height greater than 5 ft.

ii. The extinguisher by the rear Exit in the OR suite by the PACU (Petrie Division) was noted installed above 5 ft.


C. During survey of the Petrie Division and Philips Outpatient site from 09/03/13 to 09/10/13 between 11:00 AM to 4:00 PM, it was noted that many the fire extinguishers were blocked by carts and equipment , thus making the portable extinguishers not readily accessible at the time of emergency. Examples include but are not limited to:

i. The fire extinguisher in the corridor of Orange Pod of the Emergency Department was noted to be blocked by carts and a portable computer.

ii. The fire extinguisher in the Maternity suite -5th floor Dazian was noted to be blocked by portable equipment.

Note: Section 1-6.3 of NFPA 10 states that fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

D. During the survey of the generator/mechanical room in basement of Dazian on 09/10/13 at 11:45 AM, a fire extinguisher was noted to be placed on the floor and not securely installed on the wall to avoid the extinguisher being damaged by falling down.

All above findings mentioned in this tag were verified with Director of Engineering, Vice President of Facilities Operation, and staff escorting the surveyor at the time of observation/survey.

Based on documentation review and staff interview, the facility failed to ensure that all fire dampers installed in all buildings at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair and installed in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

1. On 09/05/13 at 11:50 AM, during review of fire/smoke damper assessment of Petrie Campus/Division dated 03/09/11, it was noted that many dampers had deficiencies in the different buildings of the campus. No follow up report or work order was provided to verify that those deficiencies were corrected.

2. During the inspection of the fire and smoke barriers in the facility from 09/03/13 to 09/10/13 between 11:30 AM to 4:00 PM, it was noted that that there were various ducts penetrating through the fire/smoke barrier. These ducts had fire sealant/caulking around it. The ducts were equipped with fire dampers.
NOTE: As per NFPA 90A 3-4.6 Exception: Where fire dampers are installed, proper clearance for expansion shall be maintained. (See 3-4.6.)

Therefore as per the above section, the code requires proper clearance for expansion should be maintained.
Furthermore NFPA 90A section 3-4.6.2* states that "Fire dampers, including their sleeves; smoke dampers; and ceiling dampers shall be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions".

The UL Building Material Directory also does not allow the space to be filled with any material.
Thus facility did not ensure that the ducts with fire dampers do not have their retaining angles sealed with fire caulking or sealant as that compromises the fire damper UL listing as per UL 555.

Findings were verified with the Director of Engineering and VP of Operations at the time of observation.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Furthermore, such arrangement also decreased the width of the exit access corridor from a minimum of at least 4 feet as required by NFPA 101 19.2.3.3.

Findings include:

During the tour of different parts of the facility ( Petrie Division and Philips Outpatient Building) from 09/03/13 to 09/10/13 between 11:00 AM to 4:00 PM, impediments in the path of egress were noted and the corridor width was less than 4 feet.
Examples include but are not limited to the following:
1. On 09/03/13 at 2:00 PM, during a tour of the Medical Unit-11th floor Linsky it was noted in the corridor that a stretcher/bed was parked and thus impeded the path of egress. Furthermore, the presence of the stretcher/bed decreased the width of the corridor.
2. On 09/04/13 at 12:40 PM, during the tour of the Labor and Delivery Suite -4th floor Dazian, it was noted that a IV pumps and other equipments were placed in the exit corridor near room #11.
3. On 09/06/13 at 12:00 PM, during the tour of the Ambulatory Surgical Suite at the Philips Outpatient building it was noted that , near the OR suite outside the mechanical room, there were x-ray equipment and other such items impeding the exit corridor. Furthermore, the equipment was also noted to be blocking the electrical panels.
4. On 09/09/13 at 11:30 AM, during the tour of the Central Sterile Processing Department in the basement-Karpas it was noted that the exit corridor to the clean processing area was cluttered with carts, racks, and other similar equipment.
5. On 09/09/13 between 12:00 PM to 1:00 PM, during the tour of the OR suite in the Petrie Division, various exit corridors were noted having carts, beds/stretchers, and equipment stored in a way that impeded the exit access or decreased the width or the corridor. One such example was seen by the exit corridor near OR #9.
These findings were verified with the Director of Engineering and VP of Hospital Operations at the time of observation..

Based on observation, the facility did not ensure that all trash collection receptacles with capabilities greater than 32 gallons are located in a room protected as a hazardous area when not attended.

Findings include:

On 09/03/13 at 2:00 PM during the tour of the Medical Unit-11th Floor Linsky it was noted that one large garbage container (used to store and transport garbage greater than 32 gallon) was being stored unattended in the alcove near the service elevators.

The VP of Hospital Operations acknowledged that all soiled linen/trash bags/containers, when not attended, should be stored in a room which is enclosed with a minimum of 1 hour fire resistance rated construction.

Findings were verified with the Director of Engineering and VP of Operations at the time of observation.

Based on record review and staff interview, the facility did not ensure that the piped in medical gas system's deficiencies were corrected in a timely manner and as per NFPA 99.

Findings include:

On 09/05/13 at 2:30 PM during the review of the medical gas report of the facility from 'Evergreen Medical Services' dated June 11 2013, it was noted that the report indicated many repair deficiencies, leaks, and flow failures. No follow up report was provided indicating if these deficiencies had been corrected.

Furthermore, in reviewing the past years's medical gas report of October 12/2012, it was noted that more than 85% of the current deficiencies were the same as those that were identified last year.

Therefore, this comparison indicated that facility did not have all issues identified in 2012 corrected in a timely manner to ensure patient safety.


Findings were confirmed with Director of Engineering, Assistant Director of Engineering and Vice President of Facilities Operation at the time of observation.

Based on observation in the different areas of the facility, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls and penetrations made through floors were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6

Findings include:

During the tour of the facility from 09/03/13 to 09/10/13 between 11:00 AM to 4:00 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected for the integrity of smoke barriers. The rated walls of different areas/rooms were also inspected for integrity.

It was noted that the barriers and floors were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes. These penetrations were not completely sealed all around with an approved fire retardant material to prevent passage of smoke from one compartment to the other. The penetrations made through one floor to the other in mechanical/electrical/IT closets were also observed.

Examples, include, but were not limited to:

a. On 09/13/13 at 12:30 PM , during the tour of the Emergency Department, it was noted that the fire/smoke barrier rated wall above the double had unsealed penetrations made by ducts, structural beams/studs, and pipes.

b. On 09/04/13 at 2:45 PM, during the tour of the CPEP area of Emergency Department, it was noted that the smoke barriers had miscellaneous penetrations of the rated wall with improperly sealed ducts and sleeves of wires. A great amount of duct insulation was also observed as not intact and ripped/open/vulnerable to fire conditions.

d. On 09/06/13 at 12:00 PM, during the tour of the Ambulatory Surgical Suite/Center at the Philips outpatient building, some penetrations were noted in the mechanical room made by conduits that were void of fire retardant..

c. On 09/06/13 at 12:15 PM, during the tour of the Ambulatory Surgical Suite/Center at the Philips outpatient building, the soiled utility room was noted having penetrations in the back wall, which was the rated wall as per the floor plan. It was noted that the two side walls of this room (that were also indicated to be one hour wall) did not have a wall extending from slab to slab and thus this room was not a rated room as indicated by the floor plan.

d. On 09/06/13 at 12:30 PM, during the tour of the Ambulatory Surgical Suite/Center at the Philips outpatient building, the fire barrier wall by the stairwell was noted to have penetrations that were not sealed with any fire retardant material

e. On 09/06/13 at 12:30 PM, during the tour of the Ambulatory Surgical Suite/Center at the Philips outpatient building. the smoke barrier wall (as identified by the floor plan) by the patient dressing area had many penetrations that were not sealed with any fire retardant material. Furthermore, the glass smoke door did not have any tag to indicate if it was a rated door.

f. On 09/09/13 at 2:30 PM, during the tour of the Pediatric Floor -6th floor Karpas, it was noted that the one and two hour walls of the IT/electrical closet (near the entrance to the unit) were compromised with penetrations or gaps not properly sealed with fire retardant material.

d. On 09/09/13 at 2:30 PM, during the tour of the Pediatric Floor -6th floor Karpas it was noted that the IT/electrical closet had many conduits/ penetration through the floor going to the electrical/IT room below and the penetration was not sealed with any fire retardant material.

e. On 09/10/13 at 11:30 AM, during the tour of the Maternity Floor -5th floor Dazian it was noted that the electrical closet opposite the nurse's station had penetrations of the rated wall made by conduits. Furthermore, another electrical closet after the soiled utility room had a metal frame on the rated ceiling that did not have any information noted for its rating. Therefore, it could not be verified if the rated ceiling was indeed compliant for an hour rated partition.

All above findings were verified with the Director of Engineering and Vice President for Facilities Operations at the Petrie Division at the time of observation and Director of Facilities at the Philips outpatient building at the time of survey/observation.

Note: Section 8.3.6.1 of NFPA 101 states that:

Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

b. It shall be protected by an approved device that is designed for the specific purpose.

Based on review of the emergency generator testing records and staff interview, the facility failed to ensure that the the two emergency generators installed at the Kings Highway division of the facility were tested and maintained in accordance with NFPA 110.

Findings include:

Review of the testing records of August 16, 2013 on the the two generators ( Cummins and Detroit) on 09/06/13 at approximately 11:30AM, revealed that the there was no documented evidence of testing conducted on 8 of the 9 automatic transfer switches to ensure that the required illumination was provided automatically and promptly in the event of interruption of normal lighting in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

During interview of the Director of Engineering on 09/06/13 at approximately 12:30 PM, it was stated that the transfer test on the transfer switches were conducted by the contractor, but did not document the time taken to transfer power on the testing records.

Based on document review and staff interview, facility did not ensure that the line isolation monitors were maintained in fully operating condition.

Findings include:

On 09/0505/13 at 12;15 PM, during the document review , facility was asked to provide reports for the line isolation monitors. A report dated 06/30/13 from 'PG LifeLink' was provided which indicated that there were "many panels that were non-conforming and the test values were outside established criteria".

A previous report was not provided to compare how long this issue had persisted in the family. Furthermore, no follow-up or corrective action/plan was provided regarding the plan by the facility to fix the issues noted in the report.

These findings were verified with Director of Engineering, Assistant Director of Engineering and Vice President of facilities Operation at the time of observation.

Based on document review and staff interview, it was determined that the facility performs general anesthesia and has emergency generators installed in the facility and thus requires a Type I EES (essential electrical system). The wiring of the electrical system at the panels on patient care floors in the Petrie Division are not in compliance with the code, NFPA 99 3-4, and generators are not divided into three branches.

Findings include:

1. In an interview with Director of Engineering and Vice President of Operation of Hospital Operations on 09/03/13 at 1:30 PM, the VP indicated that the wiring configuration in the facility for the Type I EES is not in compliance with 1999 NFPA 99 3-4.2.2.1. The specific issue involved was that the separation of the generator branches into a life safety, critical, and equipment system was not done for the generators and panels on patient floors were not provided for segregating the three branches. Thus the panels at the main mechanical room/switch gear room/generator has mixed wiring for life safety, critical, and equipment branches in whatever panel is present in the facility.

Document review of the panel and switches on 09/04/13 at 11:00 AM also revealed that the wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System, and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch.

1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.

Note: As per NFPA 99 Section 3-4.2.2.2
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems."
4. Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.


All above findings were verified with Director of Engineering, Vice President of Facilities Operation and engineering/electrical staff escorting the surveyor at the time of observation/survey.