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Based on observations during a Life Safety Code survey, it was noted that structural components of the facility (Andrus Pavilion and Park care) were not properly protected from fire. Issues include structural steel/steel beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type II (222) and Type I (332).

Findings include:

During tour observations of the Andrus and Park Care from 06/04/12 to 06/08/12 between 11:00 AM to 4:00 PM it was noted that the ceiling assembly located mostly throughout the buildings is comprised of lay-in ceiling tiles. However during observations above the suspended ceiling and the areas of structural steel not having suspended ceiling revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above, were not protected completely with a fire resistive material and had portions of the structural beam exposed. Such expose areas makes the beam vulnerable in case of fire.

Examples of some unprotected I-beams including, but not limited to, are:
i. On 06/04/12 at 3:30 PM during the tour of the Radiology Department in the Andrus pavilion the I-beam in the equipment room was noted to be missing fire proof material.
ii. On 06/07/12 at 11:30 AM, during the tour of the 7th floor in the Park Care building it was noted that the I-beams near the entrance to the Maintenance/Engineering space (just off the elevator) were missing fire proof material at various places. Some of the areas of I-beams inside the store room of the 7th floor also had significant amount of fire spray missing thus revealing vulnerable/bald spots on the beam. The boiler room also had I-beams exhibiting such condition.
iii. On 06/07/12 at 11:45 AM, during the survey of the 6th floor it was noted that the I-beam near the alcove (by the double door) was missing a portion of fire spray/proof material.
iv. The Pump room in Park care also had the I-beam missing considerable amount of fire proof/spray on it.
Findings were verified with Staff #18 and Staff #28.

It is to be noted that above examples are just a few examples and do not constitute the whole scenario or issue prevalent in the facility.

The facility was cited for the same issue/deficiency (in different parts of the facility though) in 03/2011 and therefore for this survey THIS IS A REPEAT DEFICIENCY.

In the Plan of Correction dated 05/17/2011 facility had stated that:
"Appropriate fire proof material will be applied to the exposed structural steel identified during inspection. (see attached vendor proposal Attachment #1). A life Safety Engineer has been retained by the hospital to perform a top to bottom survey and investigation of all structural steel in the entire facility in each of our sites for appropriate fire proofing protection to meet the minimum fire rated building construction of Type II and Type I building. Any discrepant or non-conforming locations will be identified, documented and remedied within 30 days. All findings at all sites will be reported at EOC'S monthly meeting. Responsible Party: Director of Engineering or designee. X5 date 5/27/11"

It is to be noted that when an X5 date is provided by the facility with such through explanation, then it is expected by DOH that all work will be completed by this date and in future there will be no issue and a proper monitoring mechanism will be in place. Repeat of a similar issue in a different part of the facility indicates that continuous monitoring is not in place and facility did not comply with their X5 date.

Facility did not provide any information regarding the findings of the Life Safety Engineer on the structural beam nor did facility provide any explanation why similar conditions still existed in the facility ( after promising to fix it by X5 date of 05/2011). No information in EOC committee meeting minutes was provided either regarding the discussion of the I-beams and the progress of the facility in fixing it from top to bottom in all the buildings it owns.

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

Based on observation and interview flammable chemicals used by the laboratory are not stored as required.

Findings include :

During a tour of the Dobbs Ferry hospital on 6/7/2012 at 11:30 AM, the followings were observed by the state surveyor and verified by staff #19 as follow:More than 20 gallons of Reagent alcohol that had label indicting that they were highly flammable were stored in the laboratory store room next to many other combustible materials. That flammable material should be stored in a fire rated cabinet as per NFPA 99 requirements.

Based on observation and staff interview, the facility did not ensure that the exits access are free from obstruction and are readily accessible at all times in accordance with section 7.1. 19.2.1

Findings include:

During tours of the facility from 6/4/2012 to 6/8/2012, the following were identified in the presence of staff # 19:

1. The corridors outside the Operative Rooms were used for storage of medical equipment, surgical, medical and anesthetic supplies.
2. The corridor which is also the exit way of the second floor of the hospital ( Andrus Pavilion) was observed to be obstructed by four (4) night stands, and two (2) clean linen hampers.
3. A linen cart was found being stored on the corridor outside ICU 7 next to an oxygen cylinder which is a potential for fire hazard.
4. Four (4) stretchers were found obstructing the corridor in front of the exit door of the ED.
5. The corridor outside the physical therapy area was obstructed by chairs on each side of the corridor. The corridor was observed to be used as a waiting area with two lines of seats (6 seats on each side of the corridor).
6. The corridor of the occupational therapy was partially blocked by six (6) seats and was used as a waiting area.

Based on interview there evidence that the facility ensured that emergency battery-powered lights installed in the off-site extension clinic locations were being tested in accordance with Chapter 7.9.3.

Findings include:

Staff #22 was requested on 06/08/12 at 12:45 PM to provide information regarding 90 minute yearly emergency battery back up light tests for the offsite location at Greenburgh. Staff #22 stated that he was not aware of this test and thought that the company that conducts the fire alarm test is required to do so. There was no documentation provided for any annual test.
Reviewing the other documents provided for the sprinkler test or the fire alarm test there was no information provided in those reports regarding the testing of the 90 minutes emergency battery power back up.

Note: 2000 LSC NFPA 101 Chapter 7.9.3 states that an annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspections by the authority having jurisdiction.

THIS IS A REPEAT DEFICIENCY from the survey of 03/2011. In its Plan of Correction the facility had stated that:

"'Staff will be in-serviced on proper testing requirements. Emergency lights will be inventoried, inspection report sheets will be updated, all inspections will be performed and recorded as per NFPA 101 section 7.9. Inspection Logs will be maintained in the Engineering office. Attached (see attachment #3) is the result for Andrus, Park Care & Dobbs Ferry campuses. Status of inspection and reports will be reported at the monthly EOC meetings. Floor plan showing locations of Exit and Emergency Lights for each of the clinics has been developed. the required annual 90 minute and monthly 30 second test will be performed and results will be sent to DOH upon completion. Responsible Party; Director of Engineering or Designee. X5 date 5/27/11".

No information for this extension clinic (nor any other extension clinic) was provided in the attachments in the previous survey nor was present at the site during this recent survey. This issue does not only include the emergency light at the three campuses but ALL the emergency lights at ALL extension clinics owned/operated by the facility.

Facility remains non-compliant with its plan of correction for a continuous monitoring method resulting in a repeat deficiency citation.

Based on observation and staff interview, the facility did not ensure that all directional signs are displayed in accordance with section 7.10 with continuous illumination as per 19.2.10.1

Findings include:

1. No exit sign was provided at the exit door of the OR Suite on the second floor of the hospital (Andrus Pavilion).

2. No exit sign was provided at the clean preparation area of the Central Sterile Supply.

3. The paint house and mechanical area on the 8th floor did not have exit signs to direct the staff to the exit doors in the event of fire or smoke conditions.

These findings were identified in the presence of staff # 19.

Based on document review, the facility did not ensure that the fire drills reports conducted at the Andrus Pavilion are completed and included all of the important data.

Finding includes:

Review of the fire drills documentation revealed that many of the fire drill reports were missing some entry data especially for the bell code and the zone area. The fire drill reports include data entry for the Bell Code and Zone. Those data entry lines were not completed and were left blank in most of the fire drills conducted from January 2012 till June 2012.



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Based on document review and staff interview, it was determined that the facility did not ensure that the fire drills at the off site locations such as Behavior Health Services -Greenburgh were conducted under varying conditions and that planning/ evaluation of fire drills were done as per NFPA 101

Findings include:

1. During fire drill record review on 06/08/12 at 12:15 PM, it was noted that the fire drill report of the facility is in the form of a checklist which is incomplete and highlights only a few points of the drill on which the 'observer' of the drill checks off "yes" or "no". The facility's fire drill records did not include staff sign-in sheets either and thus it was not known who was present during the drill or who was absent from the specific drill.

The facility failed to report/document a critique in the records regarding staff's fire drill response and knowledge of evacuation procedure to ensure staff is fully aware of fire drill/evacuation protocols .

2. Furthermore, review of fire drill records indicated that there was no scenario provided to ensure that the fire drills conducted 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.

Findings were verified with Staff #21.

Facility was cited for a similar deficiency in the main campus in the previous survey of 03/2011. Thus for the issue THIS IS A REPEAT DEFICIENCY.

Facility in its plan of correction had stated that:

" The fire drill procedure has been revised to reflect different scenarios for fire drill and evacuation education and staff performance. A critique and review of each drill will be made indicating deficiencies and identifying plans of corrections. Drills will be specific to individual areas. Monitoring will be reported to EOC Committee at monthly meetings. Attached (See Attachment #4) is a copy of the fire drill policy changes. Responsible Party: Director of Engineering or designee. X5 5/15/11."

The facility implemented these changes in the three hospital campuses, but not at the off-site locations. The facility did not implement correction system wide extending to its off-site locations.

Based on observation and staff interview, it was revealed that the facility did not install Fire Alarm devises as per NFPA 72.

Finding includes:

During a tour of the physical therapy area at 10:50 am, the following were identified in the presence of the director of the facilities.

1. No fire alarm strobe was provided in the patient bathroom of the waiting area outside the physical therapy area.

2. No fire alarm strobe was provided in the handicapped bathroom of the physical therapy area.

These findings were verified with staff # 19.

Based on document review and staff interview, it was determined that the hospital did not ensure that the Fire Alarm system was maintained in operating and reliable condition as per NFPA 72 7-2.2.13.h.1 and 7-1.1.2.3.1
Findings include:

Review of the Fire Alarm and Sprinkler System's maintenance records in the presence of the Director of Engineering on 6/5/2012 at 3:30 PM, revealed that the facility's fire system had two defective Water Flow Switches (7.41% of the total initiating devices) and six (6) defective Tamper Switches (15% of the total supervisory devises) that repeatedly failed the quarterly and annual tests.

The failed water flow switches include:

1. 15476598 S-1 floor South Stairwell failed test Paddle NG and its address was 1-10-1.
2. 15476378 S-4 Floor Chiller Room MER % rear @ducts was not connected and its address was 1-3-3

The Six failed Tamper Switches (15% of the total hospital tamper switches) are as follow:

1. 15476560 S-2nd Floor MIS a/c 1st office on left failed test.
2. 15476592 S-4 Floor Chiller Room between Units 4 &5 was not connected.
3. 15476593 S-4 Floor Chiller Room between Units 4&5 was not connected.
4. 15476178 S-4 Floor zone 3 rear of NER 5 behind duct was not connected
5. 15476379 S-4 floor Chiller room behind Unit 5 was not connected.
6. 14876568 2nd floor Southwest OR corridor at Nurses Locker was removed.
The above referenced devices were defective and repeatedly failed the required tests on 10/29/2011, 3/2/2012 and on 5/10/2012.
The facility did not have any interim life safety plan to address the compromised fire and sprinkler system despite their knowledge of the defective system and its potential hazards.
The above findings were verified with Staff # 20.

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 06/08/12 at 12:15 PM, Staff #22 provided the annual sprinkler report for the Greenburgh extension clinic dated 05/11/11. The report stated that 'Main Drain needs to be piped out correctly'. Facility did not have any follow up report indicating if the issue was resolved or if any correction was made or not for the problem. At 3:00 PM, Staff #21 provided surveyor with a faxed copy of a recent sprinkler test report dated 01/24/12 for the extention clinic. This report did not indicate a main drain issue however there were other issues (not clearly legible) noted in this report. It was not clear if these problems were an outcome of any previous issue or were completely new issues. No follow up for these issues was provided.


2. On 06/06/12 at 2:45 PM, during the review of the sprinkler report for the Park Care Pavilion, it was noted that the report dated 03/30/12 indicated that 4 tamper and 1 flow alarm signals were not being sent. It is to be noted that this building is not fully sprinkler.

No follow-up to this report was provided to determine if facility corrected these issues, or if the issues are still existing and if so, how has the facility ensured the safety of the building and its occupants.

Findings were confirmed by Staff #20

The issue of tamper and alarm switches not working properly is a REPEAT DEFICIENCY.

Similar issue was noted in the survey of 03/2011. Facility had responded in its plan of correction:

"All deficiencies found will be tracked into completion and re-test verification documented and maintained with the Sprinkler System reports. Other service providers are being explored and considered. Current service provider will be re-evaluated for thoroughness, accuracy and compliance. If inconsistencies are found, service provider will be terminated and replaced. An interim life safety measures for discrepancies identified in the reports will be assess and implemented until issues are resolved. An authorized sprinkler service and maintenance contractor has been retained to repair and rectify all items presented in the sprinkler inspection report. Responsible party : Director of Engineering or designee . X5 5/27/11".

No continuous monitoring method for ensuring that the sprinkler system is free from issues were noted in the facility. Moreover, no interim life safety measure and its implementation was observed in practical form and in the form of documentation.
No evidence was provided how the facility is showing its due diligence in trying to be in compliance with the code and with the plan of correction that was provided by the facility to be implemented.

Based on observation, it was determined that the facility failed to ensure that all of its portable fire extinguishers are installed in such a manner that they are not obstructed and are readily accessible during a fire situation as per NFPA 101 9.7.4.1.

Findings include:

1. During the tour of the Greenburgh Alcoholism Extension Clinic on 06/08/12 at 12:30 PM, it was noted a chair was blocking the fire extinguisher in the Group room by the offices.

The staff present there stated that this arrangement was due to a group session that recently finished. However, it is to be noted that fire extinguishers need to be free of obstruction at ALL times.

This is a REPEAT DEFICIENCY from the previous survey of 3/11, when a stack of chairs was noted blocking the same extinguisher. Facility had indicate in its plan of correction that it will educate the staff regarding this issue to assure clearance of the extinguisher. However that was not noted in this current survey.

Findings were verified with Staff #21 and Staff #22.

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.


2. During the tour of the Generator room in the Park Care Pavillion on 06/07/12 at 11:45 AM, a dedicated fire extinguisher for the area was noted sitting on the floor and not secured or hung on the wall or in a cabinet. Finding was verified with Staff #28.

It is to be noted that facility needs a system wide continuous monitoring method for the issues cited during the survey.

Based on documentation review for Andrus pavilion and staff interview, it was determined that the facility failed to ensure that all fire dampers installed 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:

1. On 06/06/12 at 11:45 AM, facility was requested to provide information for the fire/smoke dampers in the facility. Staff #20 provided fire/smoke dampers inspection report for Andrus Pavilion, conducted in the year 2009. This report revealed that out of 458 dampers, at least 52 dampers were defective or were needed, 63 were unaccessible, and for 33, access was needed for the inspecting staff. There was no follow up indicating if these issues were corrected.

It is to be noted that this is the same report that was provided to the surveyor in the survey of 03/28/2011. Therefore there was no evidence that there was follow up to the issues.
THIS IS A REPEAT DEFICIENCY.

In the plan of correction dated 05/17/2011 for the survey of 03/28/11, facility had stated that:
"Fire & Smoke Dampers in each of the facilities have been identified. The inspection reports will be reviewed and proper inspections and required inspection frequency will be followed and documented. An interim Life Safety Assessment will be performed for each non-operating. non-accessible fire/smoke dampers and an ISLM plan will be implemented and documented and forwarded to the DOH upon completion. Status of project will be reported to EOC Committee at its monthly meeting. Responsible party: Director of Engineering or Designee. X5 date 05/27/11".

2. Staff #20 provided a proposal from "C & S Building Services" dated 02/24/2012. However, the document did not have the facility (St.John's) signature on it to indicate whether it was approved or not, and there was no expected date of completion provided to the surveyor. It is to be noted that at the time of the last survey in 03/ 2011 a similar document
from the company "C & S " dated 09/16/2010 was provided to the surveyor indicating the scope of work. However, that also did not have any timeline and signature for St.John's.
The NYSDOH had approved the plan of correction since it showed that the facility has decided to show due diligence.

3. As stated in the plan of correction the facility was to implement an ISLM plan, however no information was provided if interim fire safety/ fire watch program had been in effect at the premises, pending the replacement of the dampers. This issue was also cited previously.

4. The EOC meetings of the last quarter did not contain any information on the issue of damper replacement, specially the timeline of when the facility anticipates the completion and how they will manage to maintain patient and building safety.

Findings were verified with Staff #18 and Staff #19.

Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls 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:

Operative Suite Area:
There were two penetrations around conduits and electrical wiring in the wall above the door in the electric closet on the PACU electric closet (E6), in addition to a vertical penetration around conduit in the same room.

Critical care:
The electric closet in front of room 9 had penetrations at the perimeter of the ceiling and the walls that was sealed with foam instead of the required fire stops.

Penetrations were observed around two conduits on the fire wall on the second floor elevator lobby outside the OR Suite.

Ambulatory Surgery Unit:
Penetrations were observed around the air duct and around conduits on the wall above the door of the electric closet of the endoscopy suit. Those penetrations were sealed with foam spray instead of the proper fire stops.

The Emergency Department (ED):
The smoke barrier wall next to the staff locker room had multiple penetrations around electric and data wiring.

The electric closet next to the discharge desk had multiple big penetrations in the smoke barrier and in the corridor walls.

Radiology Department:
The smoke/fire rated wall of the electric closet in the Radiology department was not extended to the deck above leaving a penetration of approximately 4 inches above the upper end of the wall that was not sealed by fire stops.

Physical Therapy Area:
No fire alarm strobe was provided in the patient bathroom of the waiting area outside the physical therapy area.

No fire alarm strobe was provided in the handicapped bathroom of the of the physical therapy area.

6th Floor West:
The fire/smoke barrier above the smoke door between the ambulatory surgery unit
and the elevator bank had multiple penetrations that were not sealed with fire stops.

6th Floor South:
The electric closet (6SE) had multiple penetrations that were sealed by insulation
material and not the proper fire stop.

All the above findings were identified in the presence of staff #19 who acknowledged them.


Dobbs Ferry

During a tour of the Dobbs Ferry hospital on 6/7/2012 at 11:30 AM, the following were observed by the state surveyor and verified by staff #19:

The smoke barrier above the smoke doors on the corridor elevator lobby to the mechanical room had a big penetration around the air duct that was > 4 " x 4 " in size.

The fire wall above the fire door to the medical record room had multiple penetrations around air ducts, and wirings.

The life safety drawing of the building of the Dobbs Ferry Extension clinic was not accurate and the fire and smoke partitions did not match the presented life safety drawing.
For instance, some of the smoke barriers presented on the drawing did not exist in its location and/or the barriers were not constructed per the life safety drawings.

Staffs #19 and #20 were interviewed and verified the above finding especially on the corridor between the lower level corridor to the engineering room.
















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Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls 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 Andrus and Park Care between from 11:15 AM to 3:45 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected to see the integrity of smoke barriers. Furthermore, the rated walls of different areas were also inspected for its integrity.

It was noted that the smoke barriers 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, are:

a. On 06/04/12 at 2:15 PM, during the tour of the Laboratory Department it was noted that the electrical closet in the Laboratory had a penetration made by a drain pipe.
b. On 06/06/12 at 2:30 PM, During the tour of the main storage area in the Andrus Pavilion it was noted that the facility has a room rated 2 hour dedicated for the storage of the oxygen cylinders. This room was noted having multiple penetrations made with wide water pipes/drain and other wires/conduits/pipes.
c. On 06/07/12 at 11:30 AM, During the tour of the generator room in the Park Care building it was noted that the room housing the generator had approximately 5 penetrations in different areas of the room made by pipes and conduits. This arrangement compromises the rated wall of the generator room.
d. Penetrations in the rated wall of the boiler room in the Park Care were noted with pipes and conduits and the wall had multiple holes through which other side of the room could be seen.
e. In Park Care, penetrations on the 6th floor above the double door were noted made with wires. As per Staff #18 and staff #28, some work of the IT(Information Technology) was being done in the building. However such condition was also noted on the 3rd floor and at the time of survey no employees/vendors/contractors were noted on any of the floor working above the double door. It is to be noted that although the work may still be in progress, if the staff leaves the area of work for a day or so, then the building becomes vulnerable to fire hazards. Therefore, some interim/temporary way should be done to fire proof the building as much as possible during any kind of work.
The finding were verified with Staff #18 and Staff #28 at the time of 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.


THIS ISSUE IS A REPEAT DEFICIENCY FROM THE PREVIOUS SURVEY OF 03/2011.

Although different areas were cited at that time however the issues of facility having penetrations was identified and facility's attention was brought towards rectifying the problem system wide. In its plan of correction dated 05/17/11 facility had stated 'All penetrations will be filled using appropriate materials, means and measure by trained and certified staff. Status of project will be reported to the EOC committee at its monthly meetings for cited items in all facilities. Plant Operation staff have been properly trained and certified by Hilti. All penetrations identified will be repaired as required. A Life Safety Engineer has been retained by the Hospital to perform a top to bottom survey and investigation of all barrier walls and structural steel in the entire facility for each of our sites for appropriate fire proofing and fire stop protection. All findings and remediation will be reported to the EOC committee at its monthly meetings. A preventive Maintenance plan will be implemented with all areas inspected at least annually and deficiencies repaired on the spot where possible or within 30 days. An ILS Assessment will be performed for each deficiency identified in the DOH report which has not been remedied. Repair and Status reports will be forwarded to the DOH upon completion. Responsible party: Director of Engineering or designee. X5 05/27/2011'.

Facility failed to implement the above plan of correction since the following verifications/documents were not provided:
i. A report from the Life Safety Engineer indicating what top to bottom survey was performed and how many or what was the extent of the penetrations found.

ii. The report of findings and remediation reported to the EOC committee at its monthly meetings and the action of discussion of the committee on the progress and its ongoing monitoring method.

iii. Verification/documentation/proof of the preventive Maintenance plan which was to be implemented implemented for all areas to be inspected at least annually and deficiencies repaired on the spot where possible or within 30 days.

iv. A copy of an ILS Assessment which was to be performed for each deficiency identified in the DOH report ( and for others too since DOH survey identifies examples of the issue and does not only concentrate on the solution of the specific example) which could not be remedied.

v. Repair and Status reports were never forwarded to the DOH upon completion nor any timeline was provided if the scope of project is/was big. X5 (completion date) of 05/27/2011 meant to DOH that all penetration issues will be rectified/completed by this date. If facility cannot complete the promised correction by the X5 date then a phased out timeline should be provided indicating the approach and extent of work which shows facility's due diligence.

Based on document review and staff interview, the facility did not test the emergency generator as per NFPA 99. 3.4.4.1.

Findings include:

Review of the monthly testing of the emergency generator revealed that two (2)out of twelve (12) monthly tests did not have the transfer switch time in the reports from May 2011 to May 2012.

This finding was verified with Employee # 20.

Based on observation, document review and staff interview, the facility did not ensure that the transfer switches for the generator 750 (which was a part of major renovation of the hospital in 1984) was labeled to indicate the three branches of the generator and had a directory to indicate what it supplied and if it was according to code. Therefore, the correct wiring of the Type 1 EES could not be confirmed during survey.

Furthermore, the branches of the Life Safety and Critical panel were not divided adequately in the OR suite, 750 kW supplies OR 6, Cysto, and Endo.

Findings include:

1. The facility is supplied by two generators that are 650 kW and 750 kW. At the time of construction in 1960 the branches of 650 kW generator were not divided and 750kW is fairly new which was a part of 'Modernization/renovation' and was divided into three branches as per the construction plans.
The part of the hospital that is being served by 650 kW has not gone under any renovation/construction nor has any part of the newly renovated area that has been a part of this existing 650 kW.

During the tour of the mechanical spaces on 06/06/12 at 2:30 PM, it was noted that the transfer switch panels of 750kW were not labeled for Life Safety, Critical and Equipment branch. Therefore it could not be determined if the wiring of the three branches was done as per code or not.

2. A tour of the OR suite was done on 06/08/12 at 3:45 PM, to see if three panels were present (coming up from the generator) and if the panels were labeled and wired accordingly. It was noted that there were three panels in the electrical closet however, they were not labeled. Furthermore, the directory indicated that two out of the three panels had lightning and outlets/receptacles wired through it and one panel was getting the feed from IP (isolation power) panels.


Therefore, 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.

3. During the Federal survey of 03/3011 facility was cited for not having three branches for generator 650 kW. At that time accurate information was not provided. During this current survey it took 5 days for the facility to explain the two generators.
The facility had promised in the survey of 2011 to request a waiver from CMS for not complying with three branches of the generator for 650 kW. It is to be noted this 650 generator supplies major portion of the Operating Suite and Critical areas which requires a Type 1 EES system.
No waiver or correspondence with CMS was provided to DOH or surveyor regarding this issue. During the current survey, the Engineering staff stated that no new connection or construction was added on 650 kW( which was a replacement to original 200 kW in 1980s), however any kind of documentation, study/verification from the engineer or any other formal complete report was not provided that the facility had shown due diligence in following up this issue, acknowledging it and justifying thoroughly the current arrangement of not having 650 kW divided into three branches and not impacting patient safety.

Based on observation, the hospital failed to ensure that electrical wiring is utilized in accordance with the National Electrical Code NFPA 70

The finding is:

On 06/06/12 at 11:55 PM, during the tour of the C-section OR in the Andrus Pavillion , it was noted that there was a power strip/multi plug adaptor which had 6 permenant equipments plugged into it. This power strip/multi plug adaptor was further connected to an extension cord and this extension cord was plugged into the main outlet. Such arrangement can lead to a significant fire hazard.
NOTE: Multi-plug adaptors/extension cords shall not be used as a substitute for permanent wiring and shall not be used for fixed or stationary appliances. Extension cords shall be plugged directly into an approved receptacle, power tap, or multi-plug adapter and shall, except for approved multi-plug extension cords, serve only one portable appliance.


NFPA 70 400-8, 210-20(b) (1) & (2) / 210-23

Based on observations during a Life Safety Code survey, it was noted that structural components of the facility (Andrus Pavilion and Park care) were not properly protected from fire. Issues include structural steel/steel beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type II (222) and Type I (332).

Findings include:

During tour observations of the Andrus and Park Care from 06/04/12 to 06/08/12 between 11:00 AM to 4:00 PM it was noted that the ceiling assembly located mostly throughout the buildings is comprised of lay-in ceiling tiles. However during observations above the suspended ceiling and the areas of structural steel not having suspended ceiling revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above, were not protected completely with a fire resistive material and had portions of the structural beam exposed. Such expose areas makes the beam vulnerable in case of fire.

Examples of some unprotected I-beams including, but not limited to, are:
i. On 06/04/12 at 3:30 PM during the tour of the Radiology Department in the Andrus pavilion the I-beam in the equipment room was noted to be missing fire proof material.
ii. On 06/07/12 at 11:30 AM, during the tour of the 7th floor in the Park Care building it was noted that the I-beams near the entrance to the Maintenance/Engineering space (just off the elevator) were missing fire proof material at various places. Some of the areas of I-beams inside the store room of the 7th floor also had significant amount of fire spray missing thus revealing vulnerable/bald spots on the beam. The boiler room also had I-beams exhibiting such condition.
iii. On 06/07/12 at 11:45 AM, during the survey of the 6th floor it was noted that the I-beam near the alcove (by the double door) was missing a portion of fire spray/proof material.
iv. The Pump room in Park care also had the I-beam missing considerable amount of fire proof/spray on it.
Findings were verified with Staff #18 and Staff #28.

It is to be noted that above examples are just a few examples and do not constitute the whole scenario or issue prevalent in the facility.

The facility was cited for the same issue/deficiency (in different parts of the facility though) in 03/2011 and therefore for this survey THIS IS A REPEAT DEFICIENCY.

In the Plan of Correction dated 05/17/2011 facility had stated that:
"Appropriate fire proof material will be applied to the exposed structural steel identified during inspection. (see attached vendor proposal Attachment #1). A life Safety Engineer has been retained by the hospital to perform a top to bottom survey and investigation of all structural steel in the entire facility in each of our sites for appropriate fire proofing protection to meet the minimum fire rated building construction of Type II and Type I building. Any discrepant or non-conforming locations will be identified, documented and remedied within 30 days. All findings at all sites will be reported at EOC'S monthly meeting. Responsible Party: Director of Engineering or designee. X5 date 5/27/11"

It is to be noted that when an X5 date is provided by the facility with such through explanation, then it is expected by DOH that all work will be completed by this date and in future there will be no issue and a proper monitoring mechanism will be in place. Repeat of a similar issue in a different part of the facility indicates that continuous monitoring is not in place and facility did not comply with their X5 date.

Facility did not provide any information regarding the findings of the Life Safety Engineer on the structural beam nor did facility provide any explanation why similar conditions still existed in the facility ( after promising to fix it by X5 date of 05/2011). No information in EOC committee meeting minutes was provided either regarding the discussion of the I-beams and the progress of the facility in fixing it from top to bottom in all the buildings it owns.

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

Based on observation and interview flammable chemicals used by the laboratory are not stored as required.

Findings include :

During a tour of the Dobbs Ferry hospital on 6/7/2012 at 11:30 AM, the followings were observed by the state surveyor and verified by staff #19 as follow:More than 20 gallons of Reagent alcohol that had label indicting that they were highly flammable were stored in the laboratory store room next to many other combustible materials. That flammable material should be stored in a fire rated cabinet as per NFPA 99 requirements.

Based on observation and staff interview, the facility did not ensure that the exits access are free from obstruction and are readily accessible at all times in accordance with section 7.1. 19.2.1

Findings include:

During tours of the facility from 6/4/2012 to 6/8/2012, the following were identified in the presence of staff # 19:

1. The corridors outside the Operative Rooms were used for storage of medical equipment, surgical, medical and anesthetic supplies.
2. The corridor which is also the exit way of the second floor of the hospital ( Andrus Pavilion) was observed to be obstructed by four (4) night stands, and two (2) clean linen hampers.
3. A linen cart was found being stored on the corridor outside ICU 7 next to an oxygen cylinder which is a potential for fire hazard.
4. Four (4) stretchers were found obstructing the corridor in front of the exit door of the ED.
5. The corridor outside the physical therapy area was obstructed by chairs on each side of the corridor. The corridor was observed to be used as a waiting area with two lines of seats (6 seats on each side of the corridor).
6. The corridor of the occupational therapy was partially blocked by six (6) seats and was used as a waiting area.

Based on interview there evidence that the facility ensured that emergency battery-powered lights installed in the off-site extension clinic locations were being tested in accordance with Chapter 7.9.3.

Findings include:

Staff #22 was requested on 06/08/12 at 12:45 PM to provide information regarding 90 minute yearly emergency battery back up light tests for the offsite location at Greenburgh. Staff #22 stated that he was not aware of this test and thought that the company that conducts the fire alarm test is required to do so. There was no documentation provided for any annual test.
Reviewing the other documents provided for the sprinkler test or the fire alarm test there was no information provided in those reports regarding the testing of the 90 minutes emergency battery power back up.

Note: 2000 LSC NFPA 101 Chapter 7.9.3 states that an annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspections by the authority having jurisdiction.

THIS IS A REPEAT DEFICIENCY from the survey of 03/2011. In its Plan of Correction the facility had stated that:

"'Staff will be in-serviced on proper testing requirements. Emergency lights will be inventoried, inspection report sheets will be updated, all inspections will be performed and recorded as per NFPA 101 section 7.9. Inspection Logs will be maintained in the Engineering office. Attached (see attachment #3) is the result for Andrus, Park Care & Dobbs Ferry campuses. Status of inspection and reports will be reported at the monthly EOC meetings. Floor plan showing locations of Exit and Emergency Lights for each of the clinics has been developed. the required annual 90 minute and monthly 30 second test will be performed and results will be sent to DOH upon completion. Responsible Party; Director of Engineering or Designee. X5 date 5/27/11".

No information for this extension clinic (nor any other extension clinic) was provided in the attachments in the previous survey nor was present at the site during this recent survey. This issue does not only include the emergency light at the three campuses but ALL the emergency lights at ALL extension clinics owned/operated by the facility.

Facility remains non-compliant with its plan of correction for a continuous monitoring method resulting in a repeat deficiency citation.

Based on observation and staff interview, the facility did not ensure that all directional signs are displayed in accordance with section 7.10 with continuous illumination as per 19.2.10.1

Findings include:

1. No exit sign was provided at the exit door of the OR Suite on the second floor of the hospital (Andrus Pavilion).

2. No exit sign was provided at the clean preparation area of the Central Sterile Supply.

3. The paint house and mechanical area on the 8th floor did not have exit signs to direct the staff to the exit doors in the event of fire or smoke conditions.

These findings were identified in the presence of staff # 19.

Based on document review, the facility did not ensure that the fire drills reports conducted at the Andrus Pavilion are completed and included all of the important data.

Finding includes:

Review of the fire drills documentation revealed that many of the fire drill reports were missing some entry data especially for the bell code and the zone area. The fire drill reports include data entry for the Bell Code and Zone. Those data entry lines were not completed and were left blank in most of the fire drills conducted from January 2012 till June 2012.



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Based on document review and staff interview, it was determined that the facility did not ensure that the fire drills at the off site locations such as Behavior Health Services -Greenburgh were conducted under varying conditions and that planning/ evaluation of fire drills were done as per NFPA 101

Findings include:

1. During fire drill record review on 06/08/12 at 12:15 PM, it was noted that the fire drill report of the facility is in the form of a checklist which is incomplete and highlights only a few points of the drill on which the 'observer' of the drill checks off "yes" or "no". The facility's fire drill records did not include staff sign-in sheets either and thus it was not known who was present during the drill or who was absent from the specific drill.

The facility failed to report/document a critique in the records regarding staff's fire drill response and knowledge of evacuation procedure to ensure staff is fully aware of fire drill/evacuation protocols .

2. Furthermore, review of fire drill records indicated that there was no scenario provided to ensure that the fire drills conducted 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.

Findings were verified with Staff #21.

Facility was cited for a similar deficiency in the main campus in the previous survey of 03/2011. Thus for the issue THIS IS A REPEAT DEFICIENCY.

Facility in its plan of correction had stated that:

" The fire drill procedure has been revised to reflect different scenarios for fire drill and evacuation education and staff performance. A critique and review of each drill will be made indicating deficiencies and identifying plans of corrections. Drills will be specific to individual areas. Monitoring will be reported to EOC Committee at monthly meetings. Attached (See Attachment #4) is a copy of the fire drill policy changes. Responsible Party: Director of Engineering or designee. X5 5/15/11."

The facility implemented these changes in the three hospital campuses, but not at the off-site locations. The facility did not implement correction system wide extending to its off-site locations.

Based on observation and staff interview, it was revealed that the facility did not install Fire Alarm devises as per NFPA 72.

Finding includes:

During a tour of the physical therapy area at 10:50 am, the following were identified in the presence of the director of the facilities.

1. No fire alarm strobe was provided in the patient bathroom of the waiting area outside the physical therapy area.

2. No fire alarm strobe was provided in the handicapped bathroom of the physical therapy area.

These findings were verified with staff # 19.

Based on document review and staff interview, it was determined that the hospital did not ensure that the Fire Alarm system was maintained in operating and reliable condition as per NFPA 72 7-2.2.13.h.1 and 7-1.1.2.3.1
Findings include:

Review of the Fire Alarm and Sprinkler System's maintenance records in the presence of the Director of Engineering on 6/5/2012 at 3:30 PM, revealed that the facility's fire system had two defective Water Flow Switches (7.41% of the total initiating devices) and six (6) defective Tamper Switches (15% of the total supervisory devises) that repeatedly failed the quarterly and annual tests.

The failed water flow switches include:

1. 15476598 S-1 floor South Stairwell failed test Paddle NG and its address was 1-10-1.
2. 15476378 S-4 Floor Chiller Room MER % rear @ducts was not connected and its address was 1-3-3

The Six failed Tamper Switches (15% of the total hospital tamper switches) are as follow:

1. 15476560 S-2nd Floor MIS a/c 1st office on left failed test.
2. 15476592 S-4 Floor Chiller Room between Units 4 &5 was not connected.
3. 15476593 S-4 Floor Chiller Room between Units 4&5 was not connected.
4. 15476178 S-4 Floor zone 3 rear of NER 5 behind duct was not connected
5. 15476379 S-4 floor Chiller room behind Unit 5 was not connected.
6. 14876568 2nd floor Southwest OR corridor at Nurses Locker was removed.
The above referenced devices were defective and repeatedly failed the required tests on 10/29/2011, 3/2/2012 and on 5/10/2012.
The facility did not have any interim life safety plan to address the compromised fire and sprinkler system despite their knowledge of the defective system and its potential hazards.
The above findings were verified with Staff # 20.

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 06/08/12 at 12:15 PM, Staff #22 provided the annual sprinkler report for the Greenburgh extension clinic dated 05/11/11. The report stated that 'Main Drain needs to be piped out correctly'. Facility did not have any follow up report indicating if the issue was resolved or if any correction was made or not for the problem. At 3:00 PM, Staff #21 provided surveyor with a faxed copy of a recent sprinkler test report dated 01/24/12 for the extention clinic. This report did not indicate a main drain issue however there were other issues (not clearly legible) noted in this report. It was not clear if these problems were an outcome of any previous issue or were completely new issues. No follow up for these issues was provided.


2. On 06/06/12 at 2:45 PM, during the review of the sprinkler report for the Park Care Pavilion, it was noted that the report dated 03/30/12 indicated that 4 tamper and 1 flow alarm signals were not being sent. It is to be noted that this building is not fully sprinkler.

No follow-up to this report was provided to determine if facility corrected these issues, or if the issues are still existing and if so, how has the facility ensured the safety of the building and its occupants.

Findings were confirmed by Staff #20

The issue of tamper and alarm switches not working properly is a REPEAT DEFICIENCY.

Similar issue was noted in the survey of 03/2011. Facility had responded in its plan of correction:

"All deficiencies found will be tracked into completion and re-test verification documented and maintained with the Sprinkler System reports. Other service providers are being explored and considered. Current service provider will be re-evaluated for thoroughness, accuracy and compliance. If inconsistencies are found, service provider will be terminated and replaced. An interim life safety measures for discrepancies identified in the reports will be assess and implemented until issues are resolved. An authorized sprinkler service and maintenance contractor has been retained to repair and rectify all items presented in the sprinkler inspection report. Responsible party : Director of Engineering or designee . X5 5/27/11".

No continuous monitoring method for ensuring that the sprinkler system is free from issues were noted in the facility. Moreover, no interim life safety measure and its implementation was observed in practical form and in the form of documentation.
No evidence was provided how the facility is showing its due diligence in trying to be in compliance with the code and with the plan of correction that was provided by the facility to be implemented.

Based on observation, it was determined that the facility failed to ensure that all of its portable fire extinguishers are installed in such a manner that they are not obstructed and are readily accessible during a fire situation as per NFPA 101 9.7.4.1.

Findings include:

1. During the tour of the Greenburgh Alcoholism Extension Clinic on 06/08/12 at 12:30 PM, it was noted a chair was blocking the fire extinguisher in the Group room by the offices.

The staff present there stated that this arrangement was due to a group session that recently finished. However, it is to be noted that fire extinguishers need to be free of obstruction at ALL times.

This is a REPEAT DEFICIENCY from the previous survey of 3/11, when a stack of chairs was noted blocking the same extinguisher. Facility had indicate in its plan of correction that it will educate the staff regarding this issue to assure clearance of the extinguisher. However that was not noted in this current survey.

Findings were verified with Staff #21 and Staff #22.

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.


2. During the tour of the Generator room in the Park Care Pavillion on 06/07/12 at 11:45 AM, a dedicated fire extinguisher for the area was noted sitting on the floor and not secured or hung on the wall or in a cabinet. Finding was verified with Staff #28.

It is to be noted that facility needs a system wide continuous monitoring method for the issues cited during the survey.

Based on documentation review for Andrus pavilion and staff interview, it was determined that the facility failed to ensure that all fire dampers installed 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:

1. On 06/06/12 at 11:45 AM, facility was requested to provide information for the fire/smoke dampers in the facility. Staff #20 provided fire/smoke dampers inspection report for Andrus Pavilion, conducted in the year 2009. This report revealed that out of 458 dampers, at least 52 dampers were defective or were needed, 63 were unaccessible, and for 33, access was needed for the inspecting staff. There was no follow up indicating if these issues were corrected.

It is to be noted that this is the same report that was provided to the surveyor in the survey of 03/28/2011. Therefore there was no evidence that there was follow up to the issues.
THIS IS A REPEAT DEFICIENCY.

In the plan of correction dated 05/17/2011 for the survey of 03/28/11, facility had stated that:
"Fire & Smoke Dampers in each of the facilities have been identified. The inspection reports will be reviewed and proper inspections and required inspection frequency will be followed and documented. An interim Life Safety Assessment will be performed for each non-operating. non-accessible fire/smoke dampers and an ISLM plan will be implemented and documented and forwarded to the DOH upon completion. Status of project will be reported to EOC Committee at its monthly meeting. Responsible party: Director of Engineering or Designee. X5 date 05/27/11".

2. Staff #20 provided a proposal from "C & S Building Services" dated 02/24/2012. However, the document did not have the facility (St.John's) signature on it to indicate whether it was approved or not, and there was no expected date of completion provided to the surveyor. It is to be noted that at the time of the last survey in 03/ 2011 a similar document
from the company "C & S " dated 09/16/2010 was provided to the surveyor indicating the scope of work. However, that also did not have any timeline and signature for St.John's.
The NYSDOH had approved the plan of correction since it showed that the facility has decided to show due diligence.

3. As stated in the plan of correction the facility was to implement an ISLM plan, however no information was provided if interim fire safety/ fire watch program had been in effect at the premises, pending the replacement of the dampers. This issue was also cited previously.

4. The EOC meetings of the last quarter did not contain any information on the issue of damper replacement, specially the timeline of when the facility anticipates the completion and how they will manage to maintain patient and building safety.

Findings were verified with Staff #18 and Staff #19.

Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls 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:

Operative Suite Area:
There were two penetrations around conduits and electrical wiring in the wall above the door in the electric closet on the PACU electric closet (E6), in addition to a vertical penetration around conduit in the same room.

Critical care:
The electric closet in front of room 9 had penetrations at the perimeter of the ceiling and the walls that was sealed with foam instead of the required fire stops.

Penetrations were observed around two conduits on the fire wall on the second floor elevator lobby outside the OR Suite.

Ambulatory Surgery Unit:
Penetrations were observed around the air duct and around conduits on the wall above the door of the electric closet of the endoscopy suit. Those penetrations were sealed with foam spray instead of the proper fire stops.

The Emergency Department (ED):
The smoke barrier wall next to the staff locker room had multiple penetrations around electric and data wiring.

The electric closet next to the discharge desk had multiple big penetrations in the smoke barrier and in the corridor walls.

Radiology Department:
The smoke/fire rated wall of the electric closet in the Radiology department was not extended to the deck above leaving a penetration of approximately 4 inches above the upper end of the wall that was not sealed by fire stops.

Physical Therapy Area:
No fire alarm strobe was provided in the patient bathroom of the waiting area outside the physical therapy area.

No fire alarm strobe was provided in the handicapped bathroom of the of the physical therapy area.

6th Floor West:
The fire/smoke barrier above the smoke door between the ambulatory surgery unit
and the elevator bank had multiple penetrations that were not sealed with fire stops.

6th Floor South:
The electric closet (6SE) had multiple penetrations that were sealed by insulation
material and not the proper fire stop.

All the above findings were identified in the presence of staff #19 who acknowledged them.


Dobbs Ferry

During a tour of the Dobbs Ferry hospital on 6/7/2012 at 11:30 AM, the following were observed by the state surveyor and verified by staff #19:

The smoke barrier above the smoke doors on the corridor elevator lobby to the mechanical room had a big penetration around the air duct that was > 4 " x 4 " in size.

The fire wall above the fire door to the medical record room had multiple penetrations around air ducts, and wirings.

The life safety drawing of the building of the Dobbs Ferry Extension clinic was not accurate and the fire and smoke partitions did not match the presented life safety drawing.
For instance, some of the smoke barriers presented on the drawing did not exist in its location and/or the barriers were not constructed per the life safety drawings.

Staffs #19 and #20 were interviewed and verified the above finding especially on the corridor between the lower level corridor to the engineering room.
















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Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls 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 Andrus and Park Care between from 11:15 AM to 3:45 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected to see the integrity of smoke barriers. Furthermore, the rated walls of different areas were also inspected for its integrity.

It was noted that the smoke barriers 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, are:

a. On 06/04/12 at 2:15 PM, during the tour of the Laboratory Department it was noted that the electrical closet in the Laboratory had a penetration made by a drain pipe.
b. On 06/06/12 at 2:30 PM, During the tour of the main storage area in the Andrus Pavilion it was noted that the facility has a room rated 2 hour dedicated for the storage of the oxygen cylinders. This room was noted having multiple penetrations made with wide water pipes/drain and other wires/conduits/pipes.
c. On 06/07/12 at 11:30 AM, During the tour of the generator room in the Park Care building it was noted that the room housing the generator had approximately 5 penetrations in different areas of the room made by pipes and conduits. This arrangement compromises the rated wall of the generator room.
d. Penetrations in the rated wall of the boiler room in the Park Care were noted with pipes and conduits and the wall had multiple holes through which other side of the room could be seen.
e. In Park Care, penetrations on the 6th floor above the double door were noted made with wires. As per Staff #18 and staff #28, some work of the IT(Information Technology) was being done in the building. However such condition was also noted on the 3rd floor and at the time of survey no employees/vendors/contractors were noted on any of the floor working above the double door. It is to be noted that although the work may still be in progress, if the staff leaves the area of work for a day or so, then the building becomes vulnerable to fire hazards. Therefore, some interim/temporary way should be done to fire proof the building as much as possible during any kind of work.
The finding were verified with Staff #18 and Staff #28 at the time of 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.


THIS ISSUE IS A REPEAT DEFICIENCY FROM THE PREVIOUS SURVEY OF 03/2011.

Although different areas were cited at that time however the issues of facility having penetrations was identified and facility's attention was brought towards rectifying the problem system wide. In its plan of correction dated 05/17/11 facility had stated 'All penetrations will be filled using appropriate materials, means and measure by trained and certified staff. Status of project will be reported to the EOC committee at its monthly meetings for cited items in all facilities. Plant Operation staff have been properly trained and certified by Hilti. All penetrations identified will be repaired as required. A Life Safety Engineer has been retained by the Hospital to perform a top to bottom survey and investigation of all barrier walls and structural steel in the entire facility for each of our sites for appropriate fire proofing and fire stop protection. All findings and remediation will be reported to the EOC committee at its monthly meetings. A preventive Maintenance plan will be implemented with all areas inspected at least annually and deficiencies repaired on the spot where possible or within 30 days. An ILS Assessment will be performed for each deficiency identified in the DOH report which has not been remedied. Repair and Status reports will be forwarded to the DOH upon completion. Responsible party: Director of Engineering or designee. X5 05/27/2011'.

Facility failed to implement the above plan of correction since the following verifications/documents were not provided:
i. A report from the Life Safety Engineer indicating what top to bottom survey was performed and how many or what was the extent of the penetrations found.

ii. The report of findings and remediation reported to the EOC committee at its monthly meetings and the action of discussion of the committee on the progress and its ongoing monitoring method.

iii. Verification/documentation/proof of the preventive Maintenance plan which was to be implemented implemented for all areas to be inspected at least annually and deficiencies repaired on the spot where possible or within 30 days.

iv. A copy of an ILS Assessment which was to be performed for each deficiency identified in the DOH report ( and for others too since DOH survey identifies examples of the issue and does not only concentrate on the solution of the specific example) which could not be remedied.

v. Repair and Status reports were never forwarded to the DOH upon completion nor any timeline was provided if the scope of project is/was big. X5 (completion date) of 05/27/2011 meant to DOH that all penetration issues will be rectified/completed by this date. If facility cannot complete the promised correction by the X5 date then a phased out timeline should be provided indicating the approach and extent of work which shows facility's due diligence.

Based on document review and staff interview, the facility did not test the emergency generator as per NFPA 99. 3.4.4.1.

Findings include:

Review of the monthly testing of the emergency generator revealed that two (2)out of twelve (12) monthly tests did not have the transfer switch time in the reports from May 2011 to May 2012.

This finding was verified with Employee # 20.

Based on observation, document review and staff interview, the facility did not ensure that the transfer switches for the generator 750 (which was a part of major renovation of the hospital in 1984) was labeled to indicate the three branches of the generator and had a directory to indicate what it supplied and if it was according to code. Therefore, the correct wiring of the Type 1 EES could not be confirmed during survey.

Furthermore, the branches of the Life Safety and Critical panel were not divided adequately in the OR suite, 750 kW supplies OR 6, Cysto, and Endo.

Findings include:

1. The facility is supplied by two generators that are 650 kW and 750 kW. At the time of construction in 1960 the branches of 650 kW generator were not divided and 750kW is fairly new which was a part of 'Modernization/renovation' and was divided into three branches as per the construction plans.
The part of the hospital that is being served by 650 kW has not gone under any renovation/construction nor has any part of the newly renovated area that has been a part of this existing 650 kW.

During the tour of the mechanical spaces on 06/06/12 at 2:30 PM, it was noted that the transfer switch panels of 750kW were not labeled for Life Safety, Critical and Equipment branch. Therefore it could not be determined if the wiring of the three branches was done as per code or not.

2. A tour of the OR suite was done on 06/08/12 at 3:45 PM, to see if three panels were present (coming up from the generator) and if the panels were labeled and wired accordingly. It was noted that there were three panels in the electrical closet however, they were not labeled. Furthermore, the directory indicated that two out of the three panels had lightning and outlets/receptacles wired through it and one panel was getting the feed from IP (isolation power) panels.


Therefore, 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.

3. During the Federal survey of 03/3011 facility was cited for not having three branches for generator 650 kW. At that time accurate information was not provided. During this current survey it took 5 days for the facility to explain the two generators.
The facility had promised in the survey of 2011 to request a waiver from CMS for not complying with three branches of the generator for 650 kW. It is to be noted this 650 generator supplies major portion of the Operating Suite and Critical areas which requires a Type 1 EES system.
No waiver or correspondence with CMS was provided to DOH or surveyor regarding this issue. During the current survey, the Engineering staff stated that no new connection or construction was added on 650 kW( which was a replacement to original 200 kW in 1980s), however any kind of documentation, study/verification from the engineer or any other formal complete report was not provided that the facility had shown due diligence in following up this issue, acknowledging it and justifying thoroughly the current arrangement of not having 650 kW divided into three branches and not impacting patient safety.

Based on observation, the hospital failed to ensure that electrical wiring is utilized in accordance with the National Electrical Code NFPA 70

The finding is:

On 06/06/12 at 11:55 PM, during the tour of the C-section OR in the Andrus Pavillion , it was noted that there was a power strip/multi plug adaptor which had 6 permenant equipments plugged into it. This power strip/multi plug adaptor was further connected to an extension cord and this extension cord was plugged into the main outlet. Such arrangement can lead to a significant fire hazard.
NOTE: Multi-plug adaptors/extension cords shall not be used as a substitute for permanent wiring and shall not be used for fixed or stationary appliances. Extension cords shall be plugged directly into an approved receptacle, power tap, or multi-plug adapter and shall, except for approved multi-plug extension cords, serve only one portable appliance.


NFPA 70 400-8, 210-20(b) (1) & (2) / 210-23