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Based on observations during a 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 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:

Observations from 03/07/11 to 03/09/11 between 11:00 AM to 4:00 PM it was noted that the ceiling assembly located throughout the Reed building is comprised of lay-in ceiling tiles. Observations above the suspended ceiling on 03/07/11 and 03/08/11 revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above, were not protected with a fire resistive material.
Examples of some unprotected I-beams including but not limited to are:
i. I-beam above the double door near the Emergency Department elevator machine room.
ii.I-beam above the drop ceiling outside the Pharmacy.
iii. H-beam and I-beam near the double door on the ground floor (that leads to North Tower) by the Wound Care Center.
iv. I-beam in the electrical closet of the Surgical Suite.

Staff #5 acknowledged that the facility has identified this situation and is in a process of addressing it. Staff #5 further verified verbally that the ceiling tiles are not rated.

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 observations made during tours, it was determined that the facility failed to ensure that corridor walls were constructed and maintained to resist the passage of smoke.

Findings include:

1. During the tour of the facility from 03/07/11 to 03/10/11 between 12:45 PM to 4:00 PM, it was noted that some areas of the corridor in the facility (that were not sprinklered) were not maintained with construction of at least 1/2 hour fire resistive rating and had penetrations. Examples, including but not limited to, are:

a. On 03/08/11, unsealed penetrations/holes made by pipes/conduits/wires were noted in the corridor outside 'Pathology MD office'

b. Penetrations made by conduit/wires were noted above drop ceiling in the wall outside Laboratory entrance. This is a suite wall as per the map.

Findings were verified with Staff #5 at the time of observation.

Based on observation and interview, it was determined that the facility did not ensure that all doors opening onto and protecting the corridors from fire/smoke in the patient treatment area, were kept free of impediments to ensure positive latching and quick closing of the doors in case of an emergency.

Findings include:

During observations of the 4th floor Med Surg unit on 03/09/11 at 2:45 PM, it was noted that patient room doors on opening into the common exit corridor had dust bins placed in front of the doorway. Such arrangement may impede the prompt closure of a door in case of fire. When brought to the unit staff's attention, the facility staff removed them.

NFPA 101 (2000 edition) 19.2.1, 19.3.6.3, (19.3.6.3.6), 7.2.

Section 8.3.2* of NFPA 101 states:
Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Based on observation, document review and staff interview, it was determined that the facility did not ensure that the one hour rated wall/smoke barrier was constructed as per NFPA 101 8.3.

Findings include:

1. During the survey of the facility, surveyor was provided with a drawing/map on 03/07/11 at 11:45 AM outlining the Life Safety Code legends and areas of the facility. The drawings were dated June 22, 2009.

On 03/08/11 at 12:45 PM, during the survey of the 1st floor North tower (drawing number A0.1) it was noted that the wall separating 'Shell space' from corridor was identified as being one hour fire rated wall in the map. However, when above ceiling inspection was made, it was noted that one part/side of the sheet rock/wall was found not extending floor to floor/slab to slab. A fire/smoke barrier is made with two sheets of sheet rock to achieve the fire rating. Facility had only one sheet rock extending slab to slab instead of both. Thus in this case the fire rating of the wall was not built to achieve 1 hour.

Finding was shared with Staff #5 who were unaware why the drawing and the actual wall differed.

I

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.

Based on interview and lack of record review, it could not be determined that the facility ensured that emergency battery-powered lights installed in the Pawling and Yorktown off-site locations were being tested in accordance with Chapter 7.9.3.

Findings include:

Staff #5 was requested on 03/10/11 at 3:15 PM to provide information regarding 30 seconds monthly and 90 minute yearly emergency battery back up light tests for the two offsite locations. Staff #5 stated that he did not have those reports/documents and was not aware if the off-site locations were conducting these tests regularly.

Based on document review and staff interview, it was determined that 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. During fire drill record review on 03/10/11 at 3:15 PM, it was noted that the fire drill report 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". Although the facility's fire drill records included staff sign-in sheets and brief comments, the facility failed to report/document detailed 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.a. Review of fire drill records indicated that although the hospital's fire drills include transmission of a fire alarm signal, the hospital failed to conduct fire drills which include simulation of various types of emergency fire conditions to ensure that each staff has a full and clear understanding of facility's fire safety plan and how to execute it successfully under the varying conditions.

2.b. Hospital fire drills also did not include utilization of different components of the fire alarm system, such as smoke detectors, sprinkler system, and others, to help ensure that staff are aware of the different bell/chime counts they elicit during drills, and they can determine if the fire alarm system is in optimal working order.

Staff #5 confirmed these findings.

Based on interview and lack of record review, it could not be determined if the hospital ensured that the fire alarm systems at the Pawling and Yorktown off-site extension clinic locations are maintained in accordance with NFPA 72.

Findings include

Staff #5 was requested on 03/10/11 at 3:15 PM to provide fire alarm reports for both 'Yorktown Heights' and 'Pawling' location. Staff #5 stated that he did not have those reports/documents and was not aware if the fire alarms were maintained and inspected as per NFPA 72.

Apart from the routine maintenance and testing, information for the smoke detector sensitivity test as required by NFPA 72, 7-3.2.1. could not be verified.

A. 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 03/10/11 at 3:30 PM, during documentation review and staff interview with Staff #5, it was revealed that no documentation 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. The documentation was requested but not provided.

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.

B.Based on interview and lack of record review, it could not be determined if the hospital ensured that the fire alarm systems at the Pawling and Yorktown off-site extension clinic locations are maintained in accordance with NFPA 72.

2. Staff #5 during interview stated that the two off-site extension clinics were equipped with sprinklers. Staff #5 was requested on 03/10/11 at 3:30 PM to provide Sprinkler maintenance and testing reports for both 'Yorktown Heights' and 'Pawling' location. Staff #5 stated that he did not have those reports/documents and was not aware if the fire alarm were maintained and inspected as per NFPA 13 and 25.

Based on observation and staff interview, it was determined that the facility failed to ensure that the artificial decorative plants displayed in the facility are not constructed of combustible material, unless otherwise rendered flame retardant.

The findings include:

On 03/08/11 at 1:45 PM, it was observed that the facility had provided at least 3 decorative artificial trees (4.0-5.0 feet tall) in the Cafeteria. On 03/11/11 at 2:45 PM, a few decorative plants were placed in the meeting room of the Maternity suite. An interview with Staff #5 at that time revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees/plants. He stated that he did not think that those plants were rendered flame retardant by any chemical treatment.

Section 8.3.6.1of NFPA 101 states that:
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

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

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Based on 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:

1. During the tour of the facility between 03/07/11 to 03/10/11 from 12:45 PM to 3:45 PM, the fire/smoke barrier above the drop ceiling of the double doors was inspected to see the integrity of smoke barriers. It was noted that the smoke barrier door by Physical Therapy on the ground floor (double door going to North tower, floor plan #A0.1) and the double door by elevator of the Emergency Department's elevator room (floor plan #A1.2), 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.

This finding was verified with Staff #5.

2. It was noted that the wall in the Electrical closet in the Radiology Department (near CAT scan room) which was fire rated as per the floor plans, had penetrations made by conduits/pipes/wires, and some holes were missing fire retardants.

3. It was noted that in the Utility room of the North Tower there were penetrations made by 3 pipes/conduits.

4. It was noted that in the Electrical/data room of the OR suite, there were pipes/conduits through which blue wires were running and they were noted to have no fire retardants. Furthermore, the head of the wall joining with the ceiling/deck exhibited gaps which were not filled with any fire retardant material.

Section 19.1.2.2*of NFPA 101 states:
Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies but are primarily intended to provide outpatient services shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by not less than 2-hour fire resistance-rated construction and the facility is not intended to provide services simultaneously for four or more health care patients who are litterborne.

Based on observation and staff interview, it was determined that the facility did not maintain the 2 hour separation between business occupancy (medical offices) and health care occupancy.

Findings include:

1. On 03/07/11 at 12:55 PM, during an above ceiling inspection it was noted that the corridor wall separating Mt.Kisco Medical group from the hospital/facility was exhibiting penetrations/holes made by conduits/wires.

2. The floor plan # A1.2 dated 06/22/09 does not put a fire rating legend on the plan for the wall rating outside this 'Business occupancy'. The separation is required to be 2 hour fire rated and Staff #5 was not aware if the separating walls were built with that rating and the floor plans were not accurately reflecting it, or the separation was just not built as per 2 hour rating.

Based on document review, it could not be verified if all elevators in the facility are equipped with fire fighter recall.

Findings include:

As per Staff #5, facility has 12 elevator cars serving patients. Staff #5 was requested on 03/10/11 at 3:45 PM to provide information regarding the fire fighter recall feature on all the elevators in the facility. During fire alarm documentation review on 03/10/11, it was noted that the fire alarm vendor noted that the recall alarm for elevator was working; however it did not indicate how many/ if all elevators were connected and working with the recall feature.

Finding was verified with Staff #5.

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.

Based on observations, it was determined that the facility did not ensure that Alcohol Based Hand Rub (ABHR) dispensers were not installed directly over or adjacent to an ignition source.

Findings include:

On 03/10/11 between 11:45 PM and 1:00 PM , it was noted that Alcohol Based Hand Rub (ABHR) dispensers were installed directly above an ignition source (i.e., electric light switches) in examination room of the Mental health unit and in the housekeeping closet of the Intensive Care unit.

Findings were shared with Staff #5.

Based on observations during a 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 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:

Observations from 03/07/11 to 03/09/11 between 11:00 AM to 4:00 PM it was noted that the ceiling assembly located throughout the Reed building is comprised of lay-in ceiling tiles. Observations above the suspended ceiling on 03/07/11 and 03/08/11 revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above, were not protected with a fire resistive material.
Examples of some unprotected I-beams including but not limited to are:
i. I-beam above the double door near the Emergency Department elevator machine room.
ii.I-beam above the drop ceiling outside the Pharmacy.
iii. H-beam and I-beam near the double door on the ground floor (that leads to North Tower) by the Wound Care Center.
iv. I-beam in the electrical closet of the Surgical Suite.

Staff #5 acknowledged that the facility has identified this situation and is in a process of addressing it. Staff #5 further verified verbally that the ceiling tiles are not rated.

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 observations made during tours, it was determined that the facility failed to ensure that corridor walls were constructed and maintained to resist the passage of smoke.

Findings include:

1. During the tour of the facility from 03/07/11 to 03/10/11 between 12:45 PM to 4:00 PM, it was noted that some areas of the corridor in the facility (that were not sprinklered) were not maintained with construction of at least 1/2 hour fire resistive rating and had penetrations. Examples, including but not limited to, are:

a. On 03/08/11, unsealed penetrations/holes made by pipes/conduits/wires were noted in the corridor outside 'Pathology MD office'

b. Penetrations made by conduit/wires were noted above drop ceiling in the wall outside Laboratory entrance. This is a suite wall as per the map.

Findings were verified with Staff #5 at the time of observation.

Based on observation and interview, it was determined that the facility did not ensure that all doors opening onto and protecting the corridors from fire/smoke in the patient treatment area, were kept free of impediments to ensure positive latching and quick closing of the doors in case of an emergency.

Findings include:

During observations of the 4th floor Med Surg unit on 03/09/11 at 2:45 PM, it was noted that patient room doors on opening into the common exit corridor had dust bins placed in front of the doorway. Such arrangement may impede the prompt closure of a door in case of fire. When brought to the unit staff's attention, the facility staff removed them.

NFPA 101 (2000 edition) 19.2.1, 19.3.6.3, (19.3.6.3.6), 7.2.

Section 8.3.2* of NFPA 101 states:
Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Based on observation, document review and staff interview, it was determined that the facility did not ensure that the one hour rated wall/smoke barrier was constructed as per NFPA 101 8.3.

Findings include:

1. During the survey of the facility, surveyor was provided with a drawing/map on 03/07/11 at 11:45 AM outlining the Life Safety Code legends and areas of the facility. The drawings were dated June 22, 2009.

On 03/08/11 at 12:45 PM, during the survey of the 1st floor North tower (drawing number A0.1) it was noted that the wall separating 'Shell space' from corridor was identified as being one hour fire rated wall in the map. However, when above ceiling inspection was made, it was noted that one part/side of the sheet rock/wall was found not extending floor to floor/slab to slab. A fire/smoke barrier is made with two sheets of sheet rock to achieve the fire rating. Facility had only one sheet rock extending slab to slab instead of both. Thus in this case the fire rating of the wall was not built to achieve 1 hour.

Finding was shared with Staff #5 who were unaware why the drawing and the actual wall differed.

I

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.

Based on interview and lack of record review, it could not be determined that the facility ensured that emergency battery-powered lights installed in the Pawling and Yorktown off-site locations were being tested in accordance with Chapter 7.9.3.

Findings include:

Staff #5 was requested on 03/10/11 at 3:15 PM to provide information regarding 30 seconds monthly and 90 minute yearly emergency battery back up light tests for the two offsite locations. Staff #5 stated that he did not have those reports/documents and was not aware if the off-site locations were conducting these tests regularly.

Based on document review and staff interview, it was determined that 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. During fire drill record review on 03/10/11 at 3:15 PM, it was noted that the fire drill report 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". Although the facility's fire drill records included staff sign-in sheets and brief comments, the facility failed to report/document detailed 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.a. Review of fire drill records indicated that although the hospital's fire drills include transmission of a fire alarm signal, the hospital failed to conduct fire drills which include simulation of various types of emergency fire conditions to ensure that each staff has a full and clear understanding of facility's fire safety plan and how to execute it successfully under the varying conditions.

2.b. Hospital fire drills also did not include utilization of different components of the fire alarm system, such as smoke detectors, sprinkler system, and others, to help ensure that staff are aware of the different bell/chime counts they elicit during drills, and they can determine if the fire alarm system is in optimal working order.

Staff #5 confirmed these findings.

Based on interview and lack of record review, it could not be determined if the hospital ensured that the fire alarm systems at the Pawling and Yorktown off-site extension clinic locations are maintained in accordance with NFPA 72.

Findings include

Staff #5 was requested on 03/10/11 at 3:15 PM to provide fire alarm reports for both 'Yorktown Heights' and 'Pawling' location. Staff #5 stated that he did not have those reports/documents and was not aware if the fire alarms were maintained and inspected as per NFPA 72.

Apart from the routine maintenance and testing, information for the smoke detector sensitivity test as required by NFPA 72, 7-3.2.1. could not be verified.

A. 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 03/10/11 at 3:30 PM, during documentation review and staff interview with Staff #5, it was revealed that no documentation 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. The documentation was requested but not provided.

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.

B.Based on interview and lack of record review, it could not be determined if the hospital ensured that the fire alarm systems at the Pawling and Yorktown off-site extension clinic locations are maintained in accordance with NFPA 72.

2. Staff #5 during interview stated that the two off-site extension clinics were equipped with sprinklers. Staff #5 was requested on 03/10/11 at 3:30 PM to provide Sprinkler maintenance and testing reports for both 'Yorktown Heights' and 'Pawling' location. Staff #5 stated that he did not have those reports/documents and was not aware if the fire alarm were maintained and inspected as per NFPA 13 and 25.

Based on observation and staff interview, it was determined that the facility failed to ensure that the artificial decorative plants displayed in the facility are not constructed of combustible material, unless otherwise rendered flame retardant.

The findings include:

On 03/08/11 at 1:45 PM, it was observed that the facility had provided at least 3 decorative artificial trees (4.0-5.0 feet tall) in the Cafeteria. On 03/11/11 at 2:45 PM, a few decorative plants were placed in the meeting room of the Maternity suite. An interview with Staff #5 at that time revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees/plants. He stated that he did not think that those plants were rendered flame retardant by any chemical treatment.

Section 8.3.6.1of NFPA 101 states that:
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

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

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Based on 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:

1. During the tour of the facility between 03/07/11 to 03/10/11 from 12:45 PM to 3:45 PM, the fire/smoke barrier above the drop ceiling of the double doors was inspected to see the integrity of smoke barriers. It was noted that the smoke barrier door by Physical Therapy on the ground floor (double door going to North tower, floor plan #A0.1) and the double door by elevator of the Emergency Department's elevator room (floor plan #A1.2), 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.

This finding was verified with Staff #5.

2. It was noted that the wall in the Electrical closet in the Radiology Department (near CAT scan room) which was fire rated as per the floor plans, had penetrations made by conduits/pipes/wires, and some holes were missing fire retardants.

3. It was noted that in the Utility room of the North Tower there were penetrations made by 3 pipes/conduits.

4. It was noted that in the Electrical/data room of the OR suite, there were pipes/conduits through which blue wires were running and they were noted to have no fire retardants. Furthermore, the head of the wall joining with the ceiling/deck exhibited gaps which were not filled with any fire retardant material.

Section 19.1.2.2*of NFPA 101 states:
Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies but are primarily intended to provide outpatient services shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by not less than 2-hour fire resistance-rated construction and the facility is not intended to provide services simultaneously for four or more health care patients who are litterborne.

Based on observation and staff interview, it was determined that the facility did not maintain the 2 hour separation between business occupancy (medical offices) and health care occupancy.

Findings include:

1. On 03/07/11 at 12:55 PM, during an above ceiling inspection it was noted that the corridor wall separating Mt.Kisco Medical group from the hospital/facility was exhibiting penetrations/holes made by conduits/wires.

2. The floor plan # A1.2 dated 06/22/09 does not put a fire rating legend on the plan for the wall rating outside this 'Business occupancy'. The separation is required to be 2 hour fire rated and Staff #5 was not aware if the separating walls were built with that rating and the floor plans were not accurately reflecting it, or the separation was just not built as per 2 hour rating.

Based on document review, it could not be verified if all elevators in the facility are equipped with fire fighter recall.

Findings include:

As per Staff #5, facility has 12 elevator cars serving patients. Staff #5 was requested on 03/10/11 at 3:45 PM to provide information regarding the fire fighter recall feature on all the elevators in the facility. During fire alarm documentation review on 03/10/11, it was noted that the fire alarm vendor noted that the recall alarm for elevator was working; however it did not indicate how many/ if all elevators were connected and working with the recall feature.

Finding was verified with Staff #5.