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 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 II (222).

The findings are:

During the survey from 03/11/13 to 03/13/13 between 11:00 AM to 4:00 PM, it was observed that the ceiling assembly located throughout the building was comprised of lay-in ceiling tiles. Observations made above the suspended ceilings, in mechanical areas and other areas where the structural beam was visible from the floor level, it was revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above were not completely protected with a fire resistive material.

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

i. Areas of the I-beam in the trash and linen chute rooms in the B2 level of Guggenheim Pavilion building.

ii. The beams in the MRI chiller room.

iii. Some areas of the beam in the main supply storage room of B2 level of Guggenheim Pavilion building.

Findings were verified with Senior Director of Engineering and VP of Operations along with Environmental Heath staff.

2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1
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Based on observations and testing, the facility failed to ensure that the fire/smoke barrier doors dividing the facility into smoke/fire compartments are maintained to provide tight smoke resistance.

Findings include:

During the facility tour on 03/11/13 at 2:15 PM, it was noted that the fire/smoke barrier doors on the 3rd floor Guggenheim Pavilion were of the swinging type and held open with electromagnetic holding devices. When the door was manually released and an attempt was made to close it, the panels of the door did not latch positively. Therefore, this situation compromised the smoke resistant status of the door and in case of fire/smoke will not provide smoke-tight partition as was intended by the building construction/arrangement.

Findings were verified with the Senior Director of Engineering and VP of Operations along with Environmental Heath staff.
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Based on observation, the facility did not ensure that all hazardous areas are safeguarded from other spaces by smoke/fire resisting partitions, and 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 Guggenheim Pavilion on 03/11/13 at 12;15 PM, it was noted that the hazardous area such as the trash chute room on B2 floor had a 'walking cane' hanging on top of the door thus preventing it from latching positively / closing completely.

2. The main medical supplies area at the B2 level of the GP building had a door that did not latch positively, and was not closing automatically when released from the magnetic lock.

3. The clean room at the B2 level of the GP building had a door that did not latch positively and thus was not closing automatically when released from the magnetic lock.

All the above findings were shared with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.
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Based on document review and staff interview, the facility did not ensure a fire drill was conducted at least quarterly on every shift. The facility did not ensure that the fire drills were conducted under varying conditions and that planning / evaluation of fire drills were done as per NFPA 101.

Findings include:

1. On 03/14/13 at 11:45 AM, during the review of the binder for fire drills it was noted that the information in the fire drill binder was co-mingled with drills conducted in non-clinical spaces owned by the facility. The documentation was such that it could not be reviewed if the facility conducted quarterly fire drill in each shift in the previous year of 2012. The Director of Safety was requested to provide quarterly drills for the patient care areas. The information was not provided to the surveyor.

2. A review of the fire drill record on 03/14/13 at 11:55 AM showed a checklist highlighting the points of the drill on which the staff conducting the drill/observer checks off "yes" or "no".

Review of fire drill records indicated that the hospital did not conduct fire drills that include 'simulation of various types of emergency fire conditions' to ensure that each staff has a full and clear understanding of the facility's fire safety plan and how to execute it successfully under the varying conditions.

The fire drills checklist or report did not indicate under what scenario the fire drill was initiated.

3. 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 procedure to ensure that the staff was fully aware of fire drill/evacuation protocols.

In one of the examples of the fire drill for department 'P5' 4th shift dated 2-21-13 under 'Specific Fire-Response Duties, ' the form had 'NO' checked off for 'staff performed their specific fire response duties in the observed areas'.

It is hand written that 'Only 1/2 of staff participated'. No evaluation regarding why only half of the staff participated in the specific drill and what was the plan for the rest of the staff who did not participate.

Findings were verified with the Directory of Fire Safety, Senior Director of Engineering, VP of Operations, and Environmental Heath staff.

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Based on record review, and staff interviews, the facility did not ensure that the components comprising the fire alarm system and automatic smoke detection system were/are maintained in a reliable and working condition as per NFPA 101 2000 9.6.1.4 and NFPA 72..

The findings include:

1. On 03/14/13 at 12:45 PM , a review of 'Fire alarm system inspection report' by Simplex Grinnell for the Guggenheim Pavilion in the period from 3rd December 2011 to 1st March 2012 revealed that the following items failed the test:

a. Analog Duct Smoke detector-5

b. Beam Smoke Detector-6

c. Duct smoke Detector- 54

d- Ionization Smoke Detector- 80

e. Photo Smoke Detector - 13

f- Pull Station- Single Action- 2

g. Water Flow Detector- 11

In the Final Deficiencies list, the report indicated 190 issues.

The facility was requested to provide follow up for all of the190 deficiencies. The Senior Director of Engineering stated that the fire alarm system of various buildings of the facility are all not in trouble free status as there are more than 20 construction projects going on. Follow up documentation was requested to ensure that all of the deficiencies in the report were for areas under construction or in other operational areas.

Some work orders were provided to the surveyor but they were not conspicuous and clear regarding how many issues were resolved and no other documentation was provided that could indicate or clarify how many of these deficiencies are in the areas of construction and how many are in the areas that are being used by patients and the public.

2. The facility did not ensure that the fire watch program (that has been implemented to protect the areas where fire alarms were not tested or disabled during construction were safe from fire hazard) was adequate to cover all times. For detail citation refer to tag K 0155.

Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.


NFPA 101, 9.6.1.4

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A. Based on document review and staff interview, it was determined that the hospital did not ensure that the sprinkler system was maintained in operating and reliable condition as per NFPA 13 and NFPA 25.

Findings include:

1. On 03/14/13 at 12:15 PM, the facility provided the annual sprinkler report for the Annenberg and Guggenheim Pavilion (GP) dated 04/12/12. The report for the Annenberg building indicated there were alarm issues. No follow up was provided for the report.

The maintenance report/work order for the GP building dated 04/02/12 indicated various failures. No follow up document was provided regarding what was the facility's plan regarding ensuring that the sprinkler system was working optimally.


2. The main drain test report did not have the comparison of the static and residual pressure, therefore it could not be verified if the differences of more than 25% between the two values were normal for the sprinkler system as per its hydraulic plate.

3. A three year Dry pipe valve full flow test for the sprinkler systems was not provided which is required by NFPA 25.


B. Based on document review and interview, it was determined that the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1

Findings include:

On 03/14/13 at 12:30 PM, during documentation review for the sprinkler test it was noted that no documentation or report was 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. It could not be verified if the gauges were recalibrated or replaced in the past five years.

The main drain reports dated 04/12/12 indicated that both the Annenberg building's and the GP building's sprinkler system was 'outdated' and did not have dates or documentation regarding when the last 5 year test was conducted.

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.


C. Based on observations, it was determined that the facility did not ensure that all sprinkler pipes are free of any foreign material and paints as per NFPA 25 and NFPA 13, Standard for the Inspection, Testing and Maintenance of Water Based Fire and Protection System.


Findings include:

During the tour of the facility from 03/11/13 to 03/15/13 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 heads by the Annenberg Escalators.

ii. Dirty and dusty sprinkler heads in the Dialysis unit's waiting room.

iii. In the Dialysis unit, a piece of red thread was noted to be stuck to one of the sprinkler head.

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 Senior Director of Engineering, VP of Operations, and Environmental Heath staff.

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Based on document review, the facility failed to ensure that all of the portable fire extinguishers are inspected for their 6 years maintenance check as per NFPA 10 4-4.3

Findings include:

On 03/14/13 at 11:55 AM, during review of the 6 year refill and maintenance test excel sheet for the portable fire extinguishers in the facility, it was noted that the facility did not ensure that it monitored and was up to date with 6 year inspection of all portable fire extinguishers.
9 fire extinguishers in the Annenberg Tower were not up to date with their 6 year inspections.

Two fire extinguishers did not have their Hydrostatic tests that were due. One fire extinguisherswas recommended to be replaced since it was obsolete. No information was provided regarding if the fire extinguishers were changed or were up to date with their 6 year inspections.

Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.

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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 in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

On 03/14/13 at 11:50AM, during review of fire/smoke damper assessment of Klingenstein Pavilion, an excel sheet report dated 11/1/2007 indicated that some dampers had deficiencies in this building. No follow up report or work order was provided to verify that those deficiencies corrected.

The Senior Director of Engineering stated that sometimes due to patients occupying an area or other reasons, the damper cannot be accessed, and therefore it is either not tested or cannot be accessed again after a deficiency is found. No documentation was provided regarding whether the facility intended to correct the deficiencies that could not be corrected earlier.

Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.

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

The findings were:

During the tour of different parts of the facility, impediments in the path of egress were noted.

1. On 03/11/13 at 2:30 PM, during a tour of the OR suite in the Guggenheim Pavilion it was noted that a stretcher was parked near the smoke barrier door in such a way that it was completely covering one leaf of the door and thus impeding the path of egress.

2. On 03/13/13 at 2:45 PM, during the tour of the Oncology Unit on the 11th floor of the Guggenheim Pavilion it was noted that a patient exercise wooden stair was stored in the egress corridor. This was an impediment in the path of egress.
Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.
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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 03/12/13 at 12:00 PM during the tour of the 6th floor in the Icahn Building, one large garbage container used to store and transport garbage greater than 32 gallon was noted stored unattended in the alcove near the service elevators.

The Director of Housekeeping acknowledged that all soiled linen/trash bags/containers, when not attended, are to be stored in a soiled utility room of the respective floors or in the main soiled holding room in the basement. These rooms are enclosed with a minimum of 1 hour fire resistance rated construction.

The storage of large garbage/linen containers in the corridor was seen in other areas of the facility including the B2 level of the Guggenheim Pavilion. Some containers were empty but some did have garbage or linen in them.

Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.
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Based on observation and staff interview, it was determined that the facility did not maintain the Manifold Oxygen pressure of the piped in medical gas system as per NFPA 99.

Findings include:

During the tour of the Oxygen farm/manifold on 03/13/14 at 3:00 PM , it was noted that the oxygen pressure of the Oxygen Manifold was reading 60 PSI.

As per NFPA 99, Table 4-3.1.2.4, the standard pressure to be maintained for oxygen delivery is 50 PSI (+5 and -0).

Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.
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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 03/11/13 to 03/13/13 from 11:00 AM to 4:00 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected for the integrity of smoke barriers. The rated walls of different areas were also inspected for integrity. The penetrations made through one floor to the other in mechanical/electrical/it closets were also observed.

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.

Examples, including but not limited to:


a. On 03/11/13 at 12:30 PM , during the tour of the B2 level of the Guggenheim Pavilion, it was noted that the fire/smoke barrier rated wall outside of the trash chute and near the linen chute (room #38) had unsealed penetrations made by ducts, structural beams and pipes.

b. On 03/11/13 at 2:45 PM, during the tour of the OR suite of the 3rd floor Guggenheim Pavilion, it was noted that the Telecom IT Hub room had miscellaneous penetrations of the fire rated wall with improperly sealed ducts and sleeves of wires.

d. On 03/12/13 a4 1:00 PM, various penetrations were noted above the drop ceiling of the smoke door by the entrance of the Psychiatric Unit 6th floor Icahn Building.

Furthermore, on the 6th floor, the mechanical room had holes in the wall and the penetrations in the electrical closet were void of fire retardant.

c. On 03/13/13 at 11:45 AM during the tour of the Cardiac Surgery Intensive Care Unit on the 5th floor Guggenheim Pavilion, the IT/electrical closet had a penetration through the floor going to the electrical/IT room below and the penetration was not sealed with any fire retardant material.

d. On 03/13/13 at 2:55 PM, during the tour of the Endoscopy suite 7th floor of the 1184 building, the IT/electrical closet had a penetration through the floor going to the electrical/IT room below and the penetration was not sealed with any fire retardant material.

There were penetrations in the mechanical room wall. It is to be noted that although the walls of the mechanical room could not be verified for its rating, this closet is within a supply room which has many supplies/combustibles stored in it. Thus penetrations may lead to a fire hazard if not sealed.


These findings were verified with the Senior Director of Engineering.


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.
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Based on staff interview and document review, the facility failed to maintain the transfer switch of the emergency generators in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4 and NFPA 110 thus allowing it to transfer in 10 seconds.

Findings include.

During the review of the transfer switch maintenance records on 03/14/13 at 1:00 PM, it was noted that the report of 1/23/13 indicated that the transfer switch AN-49 located in AN 9.1 transferred in 15 seconds'.

No information was provided regarding a follow-up corrective action for this transfer switch.

Review of the transfer switch maintenance records dated 02/22/12 indicated that many transfer switches took more than required 10 seconds.

For example:

1. A-9-GP SC2= START->6:26, TRANSFER->7:05

2. A-43-KCC S2=START->6:26, TRANSFER->7:02

3. A-19-KP B2=START->6:24, TRANSFER->6:45

The Senior Director of Engineering stated that this appeared to be a documentation error but that could not be verified during the time of the survey.

Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.

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Based on Staff interview all electrical receptacles in patient care areas were not tested and maintained as per code.

Findings include:

On 03/14/13 at 3:00 PM, the Senior Director of Engineering was requested to provide evidence that electrical receptacles in the patient care areas were tested. Staff #1 stated there were no such records..

NOTE:
As per NFPA 1999 (99 ed) section 3-3.4.2.3 Maintenance and Testing of Electrical system Testing Interval for Receptacles in Patient Care Areas.

(1) Testing shall be performed after initial installation, replacement, or servicing of the device.

(2) Additional Testing shall be performed at intervals defined by documented performance data.

The codes of NFPA 99 1999 3-3.3.3 and 3-3.3.3.2 identify the most pertinent tests required to be verified.

Facility needs to ensure full compliance with NFPA 99 Chapter 3 and NFPA 70.

Facility needs to determine the frequency of testing by evidence based data and ensure that servicing of the electrical receptacles is done as per NFPA 99 so that all receptacles are operational with no electrical leakage or any other problem.

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Based on record review, and staff interview it was determined that the facility failed to adequately implement an approved fire watch in case of a malfunctioning fire alarm system in areas under construction.

Findings include:

On 03/15/13 at 11:00 AM, a review of the documents of the fire watch for all the buildings of the facility served by the partially functional fire alarm was conducted.

It was noted that from January 2013 to March 2013, the fire watch documents revealed that the fire watch did not cover all day to provide safety to the patients and the public who may be affected in those areas not served by a fully operational and functional fire alarm.

Examples including but not limited to:

1. On 01/26/13 the fire watch did not cover the 1184 building during the period from 08:00AM to 4:00PM. The fire watch form stated that the fire watch was covered from 4:00 PM to 11:00PM. The next fire watch form stated 20:00Hrs to 24:00Hrs and then the times goes from 13:00Hrs to 15:00Hrs. The documentation indicated inadequate coverage.


2. On 01/27/13 the fire watch did not cover the 1184 building during the period from 03:00PM to 5:00PM. The fire watch form documents from 3PM to 17:00Hrs. This documentation indicated inconsitency in documenting and in adhering to a specific time format.


3. On 03/09/13 the fire watch for Icahn building did not have any time written on one of the fire watch forms thus it could not be determined when this watch occurred.

4. Between 01/22/13 to 01/23/13 the fire watch did not cover the 1184 building during the period from 12:00AM to 8:00PM.

Findings were verified with the Director of Fire Safety, Senior Director of Engineering, VP of Operations, and Environmental Health staff.
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Based on lack of document review it could not be verified if all elevators in the facility are equipped with fire fighter recall and are periodically tested.

Findings include:

On 03/12/13 at 11:30 PM, the facility staff was requested to provide information regarding the fire fighter recall feature on all of the elevators in the facility. The Senior Director of Engineering was reminded regarding the surveyor's need to see the elevator recall feature and periodic testing, however no document was provided for a review.

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

NOTE: NFPA 101 2001 9.4.6 Elevator Testing.

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

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Based on interview and lack of document review, it could not be verified if the escalator in the facility conforms to the requirements of ASME / ANSI A17.3.

Finding:

The facility has an escalator in the Annenberg Building. Due to lack of any documentation for the periodic inspection and preventive maintenance, it could not be verified during survey if the escalator conformed to all requirements of ASME/ANSI A17.3.

Refer to Tag #160.

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Based on observations, the facility did not ensure that Alcohol Based Hand Rub (ABHR) dispensers were not installed directly over or adjacent to an ignition source in many areas across the different buildings of the facility.

Life Safety Code section 19.3.2.7 does not permit the installation of Alcohol Based Hand Rub (ABHR) dispensers directly over or adjacent to an ignition source.

Findings include:

During the survey from 03/11/13 to 03/14/13 between 11:00 AM to 4:00 PM , it was noted that Alcohol Based Hand Rub (ABHR) dispensers were installed directly above an ignition source (i.e., electric light switches) in multiple locations of the facility.

Examples including but not limited to are:

1. On the 6th floor of the Icahn Building (Psych Child/Adolescent) a hand sanitizer was noted to be above the electrical receptacle by the nurse's station.

2. On the 5th floor of the Guggenheim Pavilion (CSICU unit) a hand sanitizer was noted to be above the electrical receptacle by bay #11.

3. On the 11th floor of the Guggenheim Pavilion (Oncology/BMTU Unit) a hand sanitizer was noted to be above the electrical receptacle in the Laminar Flow suite.


Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.

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 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 II (222).

The findings are:

During the survey from 03/11/13 to 03/13/13 between 11:00 AM to 4:00 PM, it was observed that the ceiling assembly located throughout the building was comprised of lay-in ceiling tiles. Observations made above the suspended ceilings, in mechanical areas and other areas where the structural beam was visible from the floor level, it was revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above were not completely protected with a fire resistive material.

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

i. Areas of the I-beam in the trash and linen chute rooms in the B2 level of Guggenheim Pavilion building.

ii. The beams in the MRI chiller room.

iii. Some areas of the beam in the main supply storage room of B2 level of Guggenheim Pavilion building.

Findings were verified with Senior Director of Engineering and VP of Operations along with Environmental Heath staff.

2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1
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Based on observations and testing, the facility failed to ensure that the fire/smoke barrier doors dividing the facility into smoke/fire compartments are maintained to provide tight smoke resistance.

Findings include:

During the facility tour on 03/11/13 at 2:15 PM, it was noted that the fire/smoke barrier doors on the 3rd floor Guggenheim Pavilion were of the swinging type and held open with electromagnetic holding devices. When the door was manually released and an attempt was made to close it, the panels of the door did not latch positively. Therefore, this situation compromised the smoke resistant status of the door and in case of fire/smoke will not provide smoke-tight partition as was intended by the building construction/arrangement.

Findings were verified with the Senior Director of Engineering and VP of Operations along with Environmental Heath staff.
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Based on observation, the facility did not ensure that all hazardous areas are safeguarded from other spaces by smoke/fire resisting partitions, and 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 Guggenheim Pavilion on 03/11/13 at 12;15 PM, it was noted that the hazardous area such as the trash chute room on B2 floor had a 'walking cane' hanging on top of the door thus preventing it from latching positively / closing completely.

2. The main medical supplies area at the B2 level of the GP building had a door that did not latch positively, and was not closing automatically when released from the magnetic lock.

3. The clean room at the B2 level of the GP building had a door that did not latch positively and thus was not closing automatically when released from the magnetic lock.

All the above findings were shared with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.
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Based on document review and staff interview, the facility did not ensure a fire drill was conducted at least quarterly on every shift. The facility did not ensure that the fire drills were conducted under varying conditions and that planning / evaluation of fire drills were done as per NFPA 101.

Findings include:

1. On 03/14/13 at 11:45 AM, during the review of the binder for fire drills it was noted that the information in the fire drill binder was co-mingled with drills conducted in non-clinical spaces owned by the facility. The documentation was such that it could not be reviewed if the facility conducted quarterly fire drill in each shift in the previous year of 2012. The Director of Safety was requested to provide quarterly drills for the patient care areas. The information was not provided to the surveyor.

2. A review of the fire drill record on 03/14/13 at 11:55 AM showed a checklist highlighting the points of the drill on which the staff conducting the drill/observer checks off "yes" or "no".

Review of fire drill records indicated that the hospital did not conduct fire drills that include 'simulation of various types of emergency fire conditions' to ensure that each staff has a full and clear understanding of the facility's fire safety plan and how to execute it successfully under the varying conditions.

The fire drills checklist or report did not indicate under what scenario the fire drill was initiated.

3. 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 procedure to ensure that the staff was fully aware of fire drill/evacuation protocols.

In one of the examples of the fire drill for department 'P5' 4th shift dated 2-21-13 under 'Specific Fire-Response Duties, ' the form had 'NO' checked off for 'staff performed their specific fire response duties in the observed areas'.

It is hand written that 'Only 1/2 of staff participated'. No evaluation regarding why only half of the staff participated in the specific drill and what was the plan for the rest of the staff who did not participate.

Findings were verified with the Directory of Fire Safety, Senior Director of Engineering, VP of Operations, and Environmental Heath staff.

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Based on record review, and staff interviews, the facility did not ensure that the components comprising the fire alarm system and automatic smoke detection system were/are maintained in a reliable and working condition as per NFPA 101 2000 9.6.1.4 and NFPA 72..

The findings include:

1. On 03/14/13 at 12:45 PM , a review of 'Fire alarm system inspection report' by Simplex Grinnell for the Guggenheim Pavilion in the period from 3rd December 2011 to 1st March 2012 revealed that the following items failed the test:

a. Analog Duct Smoke detector-5

b. Beam Smoke Detector-6

c. Duct smoke Detector- 54

d- Ionization Smoke Detector- 80

e. Photo Smoke Detector - 13

f- Pull Station- Single Action- 2

g. Water Flow Detector- 11

In the Final Deficiencies list, the report indicated 190 issues.

The facility was requested to provide follow up for all of the190 deficiencies. The Senior Director of Engineering stated that the fire alarm system of various buildings of the facility are all not in trouble free status as there are more than 20 construction projects going on. Follow up documentation was requested to ensure that all of the deficiencies in the report were for areas under construction or in other operational areas.

Some work orders were provided to the surveyor but they were not conspicuous and clear regarding how many issues were resolved and no other documentation was provided that could indicate or clarify how many of these deficiencies are in the areas of construction and how many are in the areas that are being used by patients and the public.

2. The facility did not ensure that the fire watch program (that has been implemented to protect the areas where fire alarms were not tested or disabled during construction were safe from fire hazard) was adequate to cover all times. For detail citation refer to tag K 0155.

Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.


NFPA 101, 9.6.1.4

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A. Based on document review and staff interview, it was determined that the hospital did not ensure that the sprinkler system was maintained in operating and reliable condition as per NFPA 13 and NFPA 25.

Findings include:

1. On 03/14/13 at 12:15 PM, the facility provided the annual sprinkler report for the Annenberg and Guggenheim Pavilion (GP) dated 04/12/12. The report for the Annenberg building indicated there were alarm issues. No follow up was provided for the report.

The maintenance report/work order for the GP building dated 04/02/12 indicated various failures. No follow up document was provided regarding what was the facility's plan regarding ensuring that the sprinkler system was working optimally.


2. The main drain test report did not have the comparison of the static and residual pressure, therefore it could not be verified if the differences of more than 25% between the two values were normal for the sprinkler system as per its hydraulic plate.

3. A three year Dry pipe valve full flow test for the sprinkler systems was not provided which is required by NFPA 25.


B. Based on document review and interview, it was determined that the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1

Findings include:

On 03/14/13 at 12:30 PM, during documentation review for the sprinkler test it was noted that no documentation or report was 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. It could not be verified if the gauges were recalibrated or replaced in the past five years.

The main drain reports dated 04/12/12 indicated that both the Annenberg building's and the GP building's sprinkler system was 'outdated' and did not have dates or documentation regarding when the last 5 year test was conducted.

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.


C. Based on observations, it was determined that the facility did not ensure that all sprinkler pipes are free of any foreign material and paints as per NFPA 25 and NFPA 13, Standard for the Inspection, Testing and Maintenance of Water Based Fire and Protection System.


Findings include:

During the tour of the facility from 03/11/13 to 03/15/13 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 heads by the Annenberg Escalators.

ii. Dirty and dusty sprinkler heads in the Dialysis unit's waiting room.

iii. In the Dialysis unit, a piece of red thread was noted to be stuck to one of the sprinkler head.

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 Senior Director of Engineering, VP of Operations, and Environmental Heath staff.

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Based on document review, the facility failed to ensure that all of the portable fire extinguishers are inspected for their 6 years maintenance check as per NFPA 10 4-4.3

Findings include:

On 03/14/13 at 11:55 AM, during review of the 6 year refill and maintenance test excel sheet for the portable fire extinguishers in the facility, it was noted that the facility did not ensure that it monitored and was up to date with 6 year inspection of all portable fire extinguishers.
9 fire extinguishers in the Annenberg Tower were not up to date with their 6 year inspections.

Two fire extinguishers did not have their Hydrostatic tests that were due. One fire extinguisherswas recommended to be replaced since it was obsolete. No information was provided regarding if the fire extinguishers were changed or were up to date with their 6 year inspections.

Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.

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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 in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

On 03/14/13 at 11:50AM, during review of fire/smoke damper assessment of Klingenstein Pavilion, an excel sheet report dated 11/1/2007 indicated that some dampers had deficiencies in this building. No follow up report or work order was provided to verify that those deficiencies corrected.

The Senior Director of Engineering stated that sometimes due to patients occupying an area or other reasons, the damper cannot be accessed, and therefore it is either not tested or cannot be accessed again after a deficiency is found. No documentation was provided regarding whether the facility intended to correct the deficiencies that could not be corrected earlier.

Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.

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

The findings were:

During the tour of different parts of the facility, impediments in the path of egress were noted.

1. On 03/11/13 at 2:30 PM, during a tour of the OR suite in the Guggenheim Pavilion it was noted that a stretcher was parked near the smoke barrier door in such a way that it was completely covering one leaf of the door and thus impeding the path of egress.

2. On 03/13/13 at 2:45 PM, during the tour of the Oncology Unit on the 11th floor of the Guggenheim Pavilion it was noted that a patient exercise wooden stair was stored in the egress corridor. This was an impediment in the path of egress.
Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.
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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 03/12/13 at 12:00 PM during the tour of the 6th floor in the Icahn Building, one large garbage container used to store and transport garbage greater than 32 gallon was noted stored unattended in the alcove near the service elevators.

The Director of Housekeeping acknowledged that all soiled linen/trash bags/containers, when not attended, are to be stored in a soiled utility room of the respective floors or in the main soiled holding room in the basement. These rooms are enclosed with a minimum of 1 hour fire resistance rated construction.

The storage of large garbage/linen containers in the corridor was seen in other areas of the facility including the B2 level of the Guggenheim Pavilion. Some containers were empty but some did have garbage or linen in them.

Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.
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Based on observation and staff interview, it was determined that the facility did not maintain the Manifold Oxygen pressure of the piped in medical gas system as per NFPA 99.

Findings include:

During the tour of the Oxygen farm/manifold on 03/13/14 at 3:00 PM , it was noted that the oxygen pressure of the Oxygen Manifold was reading 60 PSI.

As per NFPA 99, Table 4-3.1.2.4, the standard pressure to be maintained for oxygen delivery is 50 PSI (+5 and -0).

Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.
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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 03/11/13 to 03/13/13 from 11:00 AM to 4:00 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected for the integrity of smoke barriers. The rated walls of different areas were also inspected for integrity. The penetrations made through one floor to the other in mechanical/electrical/it closets were also observed.

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.

Examples, including but not limited to:


a. On 03/11/13 at 12:30 PM , during the tour of the B2 level of the Guggenheim Pavilion, it was noted that the fire/smoke barrier rated wall outside of the trash chute and near the linen chute (room #38) had unsealed penetrations made by ducts, structural beams and pipes.

b. On 03/11/13 at 2:45 PM, during the tour of the OR suite of the 3rd floor Guggenheim Pavilion, it was noted that the Telecom IT Hub room had miscellaneous penetrations of the fire rated wall with improperly sealed ducts and sleeves of wires.

d. On 03/12/13 a4 1:00 PM, various penetrations were noted above the drop ceiling of the smoke door by the entrance of the Psychiatric Unit 6th floor Icahn Building.

Furthermore, on the 6th floor, the mechanical room had holes in the wall and the penetrations in the electrical closet were void of fire retardant.

c. On 03/13/13 at 11:45 AM during the tour of the Cardiac Surgery Intensive Care Unit on the 5th floor Guggenheim Pavilion, the IT/electrical closet had a penetration through the floor going to the electrical/IT room below and the penetration was not sealed with any fire retardant material.

d. On 03/13/13 at 2:55 PM, during the tour of the Endoscopy suite 7th floor of the 1184 building, the IT/electrical closet had a penetration through the floor going to the electrical/IT room below and the penetration was not sealed with any fire retardant material.

There were penetrations in the mechanical room wall. It is to be noted that although the walls of the mechanical room could not be verified for its rating, this closet is within a supply room which has many supplies/combustibles stored in it. Thus penetrations may lead to a fire hazard if not sealed.


These findings were verified with the Senior Director of Engineering.


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.
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Based on staff interview and document review, the facility failed to maintain the transfer switch of the emergency generators in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4 and NFPA 110 thus allowing it to transfer in 10 seconds.

Findings include.

During the review of the transfer switch maintenance records on 03/14/13 at 1:00 PM, it was noted that the report of 1/23/13 indicated that the transfer switch AN-49 located in AN 9.1 transferred in 15 seconds'.

No information was provided regarding a follow-up corrective action for this transfer switch.

Review of the transfer switch maintenance records dated 02/22/12 indicated that many transfer switches took more than required 10 seconds.

For example:

1. A-9-GP SC2= START->6:26, TRANSFER->7:05

2. A-43-KCC S2=START->6:26, TRANSFER->7:02

3. A-19-KP B2=START->6:24, TRANSFER->6:45

The Senior Director of Engineering stated that this appeared to be a documentation error but that could not be verified during the time of the survey.

Findings were verified with the Senior Director of Engineering, VP of Operations, and Environmental Heath staff.

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Based on Staff interview all electrical receptacles in patient care areas were not tested and maintained as per code.

Findings include:

On 03/14/13 at 3:00 PM, the Senior Director of Engineering was requested to provide evidence that electrical receptacles in the patient care areas were tested. Staff #1 stated there were no such records..

NOTE:
As per NFPA 1999 (99 ed) section 3-3.4.2.3 Maintenance and Testing of Electrical system Testing Interval for Receptacles in Patient Care Areas.

(1) Testing shall be performed after initial installation, replacement, or servicing of the device.

(2) Additional Testing shall be performed at intervals defined by documented performance data.

The codes of NFPA 99 1999 3-3.3.3 and 3-3.3.3.2 identify the most pertinent tests required to be verified.

Facility needs to ensure full compliance with NFPA 99 Chapter 3 and NFPA 70.

Facility needs to determine the frequency of testing by evidence based data and ensure that servicing of the electrical receptacles is done as per NFPA 99 so that all receptacles are operational with no electrical leakage or any other problem.

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Based on record review, and staff interview it was determined that the facility failed to adequately implement an approved fire watch in case of a malfunctioning fire alarm system in areas under construction.

Findings include:

On 03/15/13 at 11:00 AM, a review of the documents of the fire watch for all the buildings of the facility served by the partially functional fire alarm was conducted.

It was noted that from January 2013 to March 2013, the fire watch documents revealed that the fire watch did not cover all day to provide safety to the patients and the public who may be affected in those areas not served by a fully operational and functional fire alarm.

Examples including but not limited to:

1. On 01/26/13 the fire watch did not cover the 1184 building during the period from 08:00AM to 4:00PM. The fire watch form stated that the fire watch was covered from 4:00 PM to 11:00PM. The next fire watch form stated 20:00Hrs to 24:00Hrs and then the times goes from 13:00Hrs to 15:00Hrs. The documentation indicated inadequate coverage.


2. On 01/27/13 the fire watch did not cover the 1184 building during the period from 03:00PM to 5:00PM. The fire watch form documents from 3PM to 17:00Hrs. This documentation indicated inconsitency in documenting and in adhering to a specific time format.


3. On 03/09/13 the fire watch for Icahn building did not have any time written on one of the fire watch forms thus it could not be determined when this watch occurred.

4. Between 01/22/13 to 01/23/13 the fire watch did not cover the 1184 building during the period from 12:00AM to 8:00PM.

Findings were verified with the Director of Fire Safety, Senior Director of Engineering, VP of Operations, and Environmental Health staff.
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Based on lack of document review it could not be verified if all elevators in the facility are equipped with fire fighter recall and are periodically tested.

Findings include:

On 03/12/13 at 11:30 PM, the facility staff was requested to provide information regarding the fire fighter recall feature on all of the elevators in the facility. The Senior Director of Engineering was reminded regarding the surveyor's need to see the elevator recall feature and periodic testing, however no document was provided for a review.

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

NOTE: NFPA 101 2001 9.4.6 Elevator Testing.

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

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