HospitalInspections.org

A. Based on observation, the facility did not ensure that corridor walls are constructed as required at the Newburgh campus. The building is not fully sprinklered.

Findings are:

1. On 3/22/10 the corridor walls outside Central Sterile Supply were found to have numerous penetrations that had not been appropriately sealed. The section of the corridor near the entrance door to the loading dock did not extend to the deck.

2. On 3/24/10 the corridor walls on the 5th floor medical surgical unit were inspected and found to have penetrations above the dropped ceiling that had not been appropriately sealed.

B. Based on observation, it was determined that the facility did not ensure the rated corridor walls are protected as required.

Findings include:

During the survey of the kitchen (Cornwall Campus) on 03/22/10 at 12:45 PM, it was noted that the double door at the entrance of the kitchen opening to the corridor was wide open and did not close/proximate after being released. It is to be noted that this door is not only protecting a rated wall, but also protecting hazardous area of kitchen. Findings were verified with Staff #28, Staff #29, and Staff #22.

Based on observation, it was determined that the facility did not ensure that the doors protecting the corridor openings in the sprinklered compartment of the building are capable of being smoke-resistant.

Findings include:

On 03/26/10 at 11:30AM, it was noted that the door of the nourishment room/kitchen on the ICU floor (Newburgh campus) did not have a latching plate and was of a swinging type. Thus in case of smoke, this door will not be able to resist smoke from either end and thus compromises the integrity of the corridor.
Findings were shared with Staff #36, Staff #33 and Staff #8.

Based on observation, the facility did not ensure that stairwells are protected as required at the Newburgh campus.

Findings include:

During a tour of the 5th floor stairwell on 3/24/10, a penetration approximately 1/2" by 10" was observed improperly sealed. Mineral wool was used alone instead of being used in conjunction with firestop material.

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.

1. During a tour of the general stores room (Newburgh campus) on 3/22/10 penetrations were observed in the in the barrier wall separating this area from the lab and a construction.

2. During a tour of the construction site for the new ambulatory surgical center (Newburgh campus) on 3/23/10 penetrations were observed in the barrier wall separating this area from the elevator shaft.

3. During a tour of the 5th floor medical surgical unit (Newburgh campus) penetrations were observed in the barrier walls on either side of the elevator lobby.


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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.

Findings include:

4.a. During the survey of the facility (Cornwall campus) between 03/22/10 and 03/24/10, surveyor was provided with a drawing/map outlining the Life Safety Code legends and areas of the facility. The drawings were dated 11/09/06.
On 03/22/10 at 3:45PM, during the survey of the kitchen, it was noted that two sides of the kitchen wall (separating the kitchen/hazardous area from adjacent area of dining room/cafeteria) were identified as being one hour fire rated wall in the map. However, when above ceiling inspection was made, the wall was found to be missing and was not floor to floor/slab to slab. Finding was shared with Staff #28 and Staff #29 who were unaware why the drawing and the actual wall differed. Staff #29 later stated that the drawings were not accurate (and these were the only drawings the facility had)
b. Similar finding was noted on 03/24/10 at 12:00PM where the one hour rated wall (dividing the Emergency Department into compartmentation) was missing and was not slab to slab/floor to floor. Findings were verified with Staff #28 and Staff #29.

5. On 03/25/10 at 12:20PM on the Dialysis/Endoscopy floor (Newburgh campus), it was noted that the electrical closet on the floor did not have a complete slab to slab/ floor to floor wall on the left side (upon entering) of the room.

A. Based on observation and interview during a tours from 3/29/10 to 4/1/10, the hospital did not ensure that hazardous areas are protected as required.

The findings are:

1. The holding area in the OR suite was converted, without approval, to a new storage area and was not separated or sprinklered.

2. The hospital created a new hazardous area as part of construction for the new laboratory. One hour separation was not provided because penetrations were observed in the wall separating the construction area from the general stores area. One hour separation was not provided between the construction area and the corridor area because there was only one sheet of 5/8" sheetrock and because the sheetrock did not extend to the deck.

3. A hazardous area was created with the ongoing construction in the rear of the medical storage/general stores area. It was protected with plastic which does not provide a one hour separation. Interview with the safety manager indicated that this construction had started two weeks earlier and would take approximately two additional weeks to complete.

4. The hospital created a new hazard area with the construction for the ambulatory surgical center. It was not a protected hazardous area because it did not provide one hour separation. There were penetrations in the fire barrier wall between the construction area and the elevator shaft diminishing the effectiveness of the barrier.

In addition to being hazardous areas NFPA requires that the above construction areas be provided with a one hour separation.
NFPA 241 Standard for Construction Alteration and Demolition Operations 8.6.2.


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

The findings include:

1. During the tour of the facility from 03/22/10 to 03/29/10, it was noted that multiple soiled utility rooms, clean utility rooms and janitor's closet did not have a self-closure installed at the door or did not latch positively. Examples are, including but not limited to:
a) On 03/22/10 at 11:45AM, it was noted that janitor's closet opening in the kitchen (Cornwall campus) did not have a self-closure at the door.
b) On 03/22/10 at 1:15PM, it was noted that janitor's closet in the PT/OT(Cornwall) unit did not have a self-closure at the door.
c) On 03/23/10 at 2:25PM, it was noted that the janitor's closet on Med/Surg unit (Cornwall-1 West) did not have a self closure at the door.
d) On 03/23/10 at 12:30PM, it was noted that there was no self closure installed on the door of the main clean linen supply room in the basement (Cornwall).
e) On 03/23/10 at 12:40PM, it was noted that the soiled linen room door in the basement (Cornwall) did not latch positively.
f) On 03/24/10 at 12:40PM, it was noted that the soiled utility door on the Pain Management floor (Cornwall) did not latch positively.
g) On 03/25/10 at 12:15PM, it was noted that the soiled utility door on the ICU floor (Newburgh) did not latch positively. Similarly the soiled utility door in the Stepdown ICU unit did not latch positively.

2. On 03/23/10 at 12:00PM during the tour of the basement at Cornwall campus, it was noted that the paint shop did not have any self closure installed at the door. The room had abundant supply of paints and other liquids. It was also noted that combustibles such as cardboard boxes, cleaning cloths, and others was also stored among the hazard materials.

3. On 03/23/30 at 3:00PM, it was noted that the doors leading to Laboratory (Cornwall campus) were wide open and did not have any self closure installed at the door. This practice not only prevents the protection of the hazardous area, it also compromises the air pressure that is required to be maintained in laboratories as per NFPA 45 6-3.3. As per code 'The air pressure in the laboratory work areas shall be negative with respect to corridors and non-laboratory areas'

LSC NFPA 101, 19.3.2.1, 8.3.6,
All the above findings were shared with and brought to the attention of, escorts accompanying the surveyor at the time, such as Staff #22, Staff #28, Staff #29, Staff #30 and Staff #31.

Section 7.2.1.5.1 of NFPA 101 states that:
Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.

Based on observation and staff interview, it was determined that the facility failed to meet the above requirement and did not ensure that doors on the egress side were not equipped with locks requiring keys.

Findings include:

On 03/29/10 at 11:45AM, during a tour of the Birthing Center (postpartum suite) in Newburgh campus, it was noted that an exit door on the floor (opposite nourishment room and coat closet) leading to the stairwell was locked and required a key to be opened.
Staff #29 was asked if there was a special reason why this exit door was completely locked (unlike using an alternative such as alarmed door or delayed egress door, if required by the program) on this maternity floor. Staff #29 stated he did not know the reason why this door was locked in such arrangement.

Based on observation, it was determined that the Newburgh Campus' extension clinics did not ensure that all its emergency back up lights were operational, in good repair, and capable of supplying light for 1 1/2 hours.

Findings include:

During tour of the off-site Rehabilitation Outpatient Center (at Newburgh 9W) on 03/24/10 at 2:15PM, it was noted that an emergency battery backup light by the gym area was flickering and was not operational.
Finding was verified with Staff #28.

Based on record review and interview, the hospital did not ensure that the fire alarm system is maintained in accordance with NFPA 72.

Findings include:

1a. The fire alarm (FA) inspection report for the Newburgh Campus dated 2/8/10 does not show that notification appliances (strobes, horns etc.) were tested.
b. The FA report dated 2/8/10 in the vendor's summary test result reports that door holders throughout the facility were not tested.
c. There was no documentation available to show that issues identified in the summary FA report issued by the vendor were addressed. These issues include, but are not limited to, communication trouble signal for zones 15 and 20; and failure of primary recall for elevator #3.


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2. During the pre-opening conference on 03/22/10 at the Newburgh Campus, the facility was given a list of documents required for the survey. On 03/23/10 at 10:45AM during the tour of the Cornwall campus, surveyor asked Staff #29 about those documents, in particular referencing the fire alarm report for the Cornwall campus. Staff #29 stated that all documents were stored in the main Newburgh campus and that the surveyor will be provided with the required documents when on-site visit to Newburgh will be conducted.

On 03/29/10 at 12:00PM at Newburgh campus, Staff #29 was asked for the fire alarm reports and the surveyor was told that the documents were brought to the Cornwall campus. After exit conference of the survey on 03/29/10 at 2:45PM, surveyor was provided with one fire report for Cornwall Campus dated 02/09/10. This report was only for alarm devices on 2nd floor of the Cornwall Campus (with some ancillary space/rooms on first floor) and therefore did not provide information for the fire alarm system of the entire building/Cornwall campus.

Furthermore, the report indicated 'Mental Health' on 2nd floor and approximately 2/3 of the alarm devices were not tested due to construction in the report. During survey of the Cornwall campus, staff did not identify any space as 'Mental Health' floor/unit, thus it is unclear for which area this report reflects.

Due to this situation, it could not be verified if the facility was maintaining the fire alarm system as per NFPA 72 and what interim life safety measures the facility is utilizing to ensure safety in the areas where the alarm devices were not tested.

3. During the tour of the Cornwall campus, based on feedback given to the surveyor by Staff #29, the facility did not conduct sensitivity test on all smoke detectors installed in the facility, thus did not have sensitivity test reports for all the smoke detectors as required by NFPA 72, 7-3.2.1. This was verified by Staff #31 who stated that both campuses do not have the test reports.

Based on record review and interview the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25.

Findings include:

1. Review of the vendor's sprinkler inspection report dated 11/13/09 indicates that internal inspections for obstructions were not conducted on the sprinkler piping, the alarm valves and associated trim, and check valves at the Newburgh campus.

2. Similar finding was noted on 03/29/10 at 11:45AM during the inspection of the sprinkler report for Cornwall campus dated 02/09/10, in which no information was provided regarding the 5 year alarm/valves and internal inspection requirement. Finding was verified with Staff #29.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed conspicuously and that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10).

Findings include:

1. During the survey tour on 03/22/10 at 1:45PM of the PT/OT unit at Cornwall, it was noted that a portable fire extinguisher in the occupational therapy room was installed on the wall with its topmost portion at 64 inches above the floor. This finding was verified with Staff #22 and Staff #28

2. During the survey tour of the ICU unit on 03/26/10 at 12:45PM, it was noted that a fire extinguisher was placed in a recess cabinet in the corridor outside a patient room. No sign was posted above the fire extinguisher and a portable/movable soiled linen cart was parked nearby which partially hindered the view of the fire extinguisher. Findings were verified with Staff #36 and Staff #8.

3. Similar finding was noted on 03/23/10 at 12:00PM on Cornwall campus, 1st floor (1 west unit patient med/surg rooms) where the fire extinguisher in the corridor did not have a conspicuous sign to readily identify it from each end of the corridor. This finding was verified with Staff #22 and Staff #28.

Based on documentation review, 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:

On 03/29/10 at 12:10PM, during review of fire/smoke damper report/assessment sheet from 'Hawk Solutions' for Cornwall campus, it was noted that a damper #1-13 was found defective on 10/23/2006. No follow up report or work order was provided to verify that the defective fire damper was replaced/repaired. Finding was verified with Staff #29.

Section 8-2* of NFPA 96 states that:
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Based on document review, it was determined that the facility did not conduct semi-annual inspections on the exhaust hoods of the cooking appliances in the kitchen as required by the code.

Findings include:

On 03/29/10 at 11:50AM, Staff #29 provided the surveyor with the exhaust hood inspection reports from 2007-2009 for Cornwall campus. It was noted that the reports from 'Haight' were yearly and were dated 06/20/07, 05/30/08, and 12/07/09, respectively. Staff #29 stated there were no other semi-annual reports.

Based on observation, means of egress at the Newburgh campus are not always maintained free of impediments.

Findings include:

On 3/25/10, the exit door from the rear of the medical supply/general stores area was blocked by construction equipment and plastic sheeting. There was no doorway in the barrier erected to separate the construction from the storage area. There was no signage to provide an alternate route, or signage in front of the barrier to indicate that egress was provided on the other side.

Based on observations, the facility did not ensure that bulk oxygen storage tanks were stored in a safe manner protected from the elements, and that the storage area was clear of debris as per NFPA 99 4-3.1.2.2

Findings include:

1(a) During the tour of the Cornwall campus on 03/23/10 at 11:15AM, it was noted that an abundant amount of twigs and dried leaves was lying around the Oxygen bulk tank. Accumulation of decayed foliage and debris, such as dead decayed leaves, was noted on the entire concrete pad around and underneath the storage area of liquid oxygen tanks. Dead dried leaves are combustible and catch fire easily. Findings were verified with Staff #28 and Staff #29.
(b) Similar finding of dead leaves around the Oxygen bulk tank was found during the survey of Newburgh facility grounds. Findings were verified with Staff #31 and Staff #30.

2. During the survey of the facility grounds (Newburgh) on 02/25/10 at 3:30PM, it was noted that there was a reserve oxygen tank room (housing portable Oxygen tanks) located nearing the parking lot, outside the hospital building. This room was found open and not secured at the time of survey. The door of the room had a padlock but the padlock was not locked/closed. Furthermore, the outside fence was also not locked and no staff from engineering/facilities was present nearby. Findings were verified with Staff #31 and Staff #30.

Based on observation and staff interview it was determined that the facility did not maintain the piped in medical gas system as per NFPA 99.

Findings include:

1. On 03/23/10 11:00AM, during the tour of the Emergency Department (ED) (Cornwall campus), it was noted that the oxygen pressure reading on one of the two main medical gas alarm panel in the ED was reading as 49 PSI and other was reading 48 PSI. Staff was asked regarding the alarm/cut off points but they were not aware at what point the panels would alarm. It is to be noted that as per NFPA 99, Table 4-3.1.2.4, the standard pressure for oxygen delivery to be maintained is 50 PSI +5 and -0.

2. Similarly on 03/24/10 at 3:15PM, it was noted that in the main medical gas alarm panel at the Wound Center (Cornwall campus), oxygen reading was fluctuation as 46.7 PSI-47.7 PSI. As per Staff #34, the manufacturer's recommendation and manual specify oxygen at 50 PSI. Furthermore, it was noted that in one of the morning sessions, staff noted on the hyperbaric check list that the oxygen pressure was 49 PSI. Facility did not provide a policy for the cut off point or what if any are the side effects of not delivering oxygen at the required pressure, especially at the hyperbaric chamber.

2. On 03/29/10 at 12:30PM during the review of the medical gas report from 'Medigas' dated 06/29/09-07/02/09, it was noted that the report indicated 24 deficiencies. Out of these 24 deficiencies, corrective action follow-up was done and provided for only 5 deficiencies. No follow-up was done or provided regarding the other deficiencies.

Based on record review and interview, the facility did not ensure that humidity in the ORs is maintained as required.

The finding is:

On 3/23/10, review of the temperature and humidity logs for the ORs for the past 4 months reveals humidity levels below acceptable levels. Most days humidity was less than 20%. There was no documentation produced to indicate that corrective action was taken. The clinical nurse manager stated that these readings do not represent an accurate picture because they are taken at 5:00 AM and that during OR procedures the humidly rises to an acceptable level. The facility did not provide any documentation to show that humidity levels increased during surgery.

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 (Cornwall campus) between 03/22/10 to 03/24/10, 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 by PT/OT unit and the radiology main entrance were penetrated by ducts, pipes, conduits, cables, wires for light and other miscellaneous holes. None of the penetrations were sealed completely with an approved fire retardant material to prevent passage of smoke from one compartment to the other. This finding was verified with Staff #28 and Staff #29.

2. It was noted that the wall in the Occupational Therapy room in Cornwall campus (which was fire rated as per the floor plans) had penetrations made by conduits, fire dampers, medical gas and fiber optics, and some holes were missing fire retardants.

3. The IT room in the basement (Cornwall campus) was noted to have penetrations made by 3 silver conduits. Pipes/conduits through which blue wires were going were also noted to have no fire retardants.

A. Suites of sleeping rooms shall not exceed 5000 sq. ft.
NFPA 101 2000 18.2.5.6

Based on observation and document review, the facility did not meet the sleeping room requirements at the Newburgh campus.

Findings include:

The newly renovated sleeping suites on the 2nd, 3rd, 4th, 5th and 7th floors were greater than 10,000 sq. ft. and were not separated.


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B. Section 3-4.1-1.15, NFPA 99, requires that a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12).

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.

(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
(1) Low lubricating oil pressure
(2) Low water temperature (below those required in 3-4.1.1.9)
(3) Excessive water temperature
(4) Low fuel-when the main fuel storage tank contains less than a 3-hour operating supply.
(5) Overcrank (failed to start)
(6) Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. (110:3-5.5.2)

Based on observation, and staff interview during the survey between 03/22/10 and 03/29/10, the facility did not ensure that remote annunciators for 2 generators, at the buildings of the main Newburgh campus, are provided to operate outside of the generating room so as to indicate the alarm conditions stated under Section 3.4.1.1.15 of NFPA 99. The generator at the Cornwall campus did not have the annunciator installed in a location that is serviced by operating personnel for 24 hours.

Findings include:

1. On 03/24/10 at 3:45PM, during tour it was observed that the Cornwall campus has an remote annunciator installed in the mechanical room for its one generator on campus. Staff #28 stated that this annunciator does not have any derangement signals (as required by the code above) at a 24/7 manned station in the facility. Staff #28 stated that this mechanical room is not always occupied and that the engineering staff are out on the facility grounds performing their respective tasks.

2. On 03/25/10 at 2:30PM, during tour it was noted that the Newburgh campus maintains life support equipment to provide general anesthesia in the operating room and for ventilators in the CCU and NICU units. The facility has installed 2 generators to provide emergency power to the facility, including life support equipment, in case the normal electrical power to the facility is lost. The operating rooms are supplied by both generators. Remote annunciator panel/s outside of the generator room and an audible and visual derangement signal for alarm conditions were not provided at a constantly attended location for the conditions under 3.4.1.1.15. Findings were verified with Staff #31 and Staff #30.

C. As per NFPA 101, section 7.2.1.5.4 requires that: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Based on observation, the facility did not ensure that the exit door at the Rehabilitation Center (Newburgh-9W) meets the above requirement.

Findings include:

During the survey tour of the off-site Rehabilitation Center (at Newburgh 9W) on 03/24/10 at 1:40PM, it was noted that the rear Exit door (which is used for patient entrance also) had a thumb-twisting latching/lock installed on the door, and a lock operated by a key. When fully engaged, the thumb- twisting latching device prevents the door from opening in an obvious, one step operation required during fire/emergency evacuation. Finding was verified with Staff #32 and Staff #28.

Based on observation, it was determined that the facility did not ensure that 'No smoking' signs were installed around the fence where bulk oxygen was stored.

Findings include:

During the tour of the facility grounds between 03/22/10 and 03/29/10, it was noted that the area where bulk storage was located did not have any no smoking sign installed around the fence.
Findings were verified with Staff #28, Staff #29, Staff #30 and Staff #31.

Based on document review, it was noted that the facility did not ensure that all the elevators serving the patient care areas are certified to have firefighter recall feature installed.

Findings include:

During documentation review on 03/29/10 at 12:30 PM, it was noted that the inspection report from SimplexGrinnell, dated 03/26/10, indicated that Cornwall campus elevators number 1, 2 and 7 do not have the firefighter feature installed.

A. Based on observation, the facility did not ensure that corridor walls are constructed as required at the Newburgh campus. The building is not fully sprinklered.

Findings are:

1. On 3/22/10 the corridor walls outside Central Sterile Supply were found to have numerous penetrations that had not been appropriately sealed. The section of the corridor near the entrance door to the loading dock did not extend to the deck.

2. On 3/24/10 the corridor walls on the 5th floor medical surgical unit were inspected and found to have penetrations above the dropped ceiling that had not been appropriately sealed.

B. Based on observation, it was determined that the facility did not ensure the rated corridor walls are protected as required.

Findings include:

During the survey of the kitchen (Cornwall Campus) on 03/22/10 at 12:45 PM, it was noted that the double door at the entrance of the kitchen opening to the corridor was wide open and did not close/proximate after being released. It is to be noted that this door is not only protecting a rated wall, but also protecting hazardous area of kitchen. Findings were verified with Staff #28, Staff #29, and Staff #22.

Based on observation, it was determined that the facility did not ensure that the doors protecting the corridor openings in the sprinklered compartment of the building are capable of being smoke-resistant.

Findings include:

On 03/26/10 at 11:30AM, it was noted that the door of the nourishment room/kitchen on the ICU floor (Newburgh campus) did not have a latching plate and was of a swinging type. Thus in case of smoke, this door will not be able to resist smoke from either end and thus compromises the integrity of the corridor.
Findings were shared with Staff #36, Staff #33 and Staff #8.

Based on observation, the facility did not ensure that stairwells are protected as required at the Newburgh campus.

Findings include:

During a tour of the 5th floor stairwell on 3/24/10, a penetration approximately 1/2" by 10" was observed improperly sealed. Mineral wool was used alone instead of being used in conjunction with firestop material.

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.

1. During a tour of the general stores room (Newburgh campus) on 3/22/10 penetrations were observed in the in the barrier wall separating this area from the lab and a construction.

2. During a tour of the construction site for the new ambulatory surgical center (Newburgh campus) on 3/23/10 penetrations were observed in the barrier wall separating this area from the elevator shaft.

3. During a tour of the 5th floor medical surgical unit (Newburgh campus) penetrations were observed in the barrier walls on either side of the elevator lobby.


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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.

Findings include:

4.a. During the survey of the facility (Cornwall campus) between 03/22/10 and 03/24/10, surveyor was provided with a drawing/map outlining the Life Safety Code legends and areas of the facility. The drawings were dated 11/09/06.
On 03/22/10 at 3:45PM, during the survey of the kitchen, it was noted that two sides of the kitchen wall (separating the kitchen/hazardous area from adjacent area of dining room/cafeteria) were identified as being one hour fire rated wall in the map. However, when above ceiling inspection was made, the wall was found to be missing and was not floor to floor/slab to slab. Finding was shared with Staff #28 and Staff #29 who were unaware why the drawing and the actual wall differed. Staff #29 later stated that the drawings were not accurate (and these were the only drawings the facility had)
b. Similar finding was noted on 03/24/10 at 12:00PM where the one hour rated wall (dividing the Emergency Department into compartmentation) was missing and was not slab to slab/floor to floor. Findings were verified with Staff #28 and Staff #29.

5. On 03/25/10 at 12:20PM on the Dialysis/Endoscopy floor (Newburgh campus), it was noted that the electrical closet on the floor did not have a complete slab to slab/ floor to floor wall on the left side (upon entering) of the room.

A. Based on observation and interview during a tours from 3/29/10 to 4/1/10, the hospital did not ensure that hazardous areas are protected as required.

The findings are:

1. The holding area in the OR suite was converted, without approval, to a new storage area and was not separated or sprinklered.

2. The hospital created a new hazardous area as part of construction for the new laboratory. One hour separation was not provided because penetrations were observed in the wall separating the construction area from the general stores area. One hour separation was not provided between the construction area and the corridor area because there was only one sheet of 5/8" sheetrock and because the sheetrock did not extend to the deck.

3. A hazardous area was created with the ongoing construction in the rear of the medical storage/general stores area. It was protected with plastic which does not provide a one hour separation. Interview with the safety manager indicated that this construction had started two weeks earlier and would take approximately two additional weeks to complete.

4. The hospital created a new hazard area with the construction for the ambulatory surgical center. It was not a protected hazardous area because it did not provide one hour separation. There were penetrations in the fire barrier wall between the construction area and the elevator shaft diminishing the effectiveness of the barrier.

In addition to being hazardous areas NFPA requires that the above construction areas be provided with a one hour separation.
NFPA 241 Standard for Construction Alteration and Demolition Operations 8.6.2.


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

The findings include:

1. During the tour of the facility from 03/22/10 to 03/29/10, it was noted that multiple soiled utility rooms, clean utility rooms and janitor's closet did not have a self-closure installed at the door or did not latch positively. Examples are, including but not limited to:
a) On 03/22/10 at 11:45AM, it was noted that janitor's closet opening in the kitchen (Cornwall campus) did not have a self-closure at the door.
b) On 03/22/10 at 1:15PM, it was noted that janitor's closet in the PT/OT(Cornwall) unit did not have a self-closure at the door.
c) On 03/23/10 at 2:25PM, it was noted that the janitor's closet on Med/Surg unit (Cornwall-1 West) did not have a self closure at the door.
d) On 03/23/10 at 12:30PM, it was noted that there was no self closure installed on the door of the main clean linen supply room in the basement (Cornwall).
e) On 03/23/10 at 12:40PM, it was noted that the soiled linen room door in the basement (Cornwall) did not latch positively.
f) On 03/24/10 at 12:40PM, it was noted that the soiled utility door on the Pain Management floor (Cornwall) did not latch positively.
g) On 03/25/10 at 12:15PM, it was noted that the soiled utility door on the ICU floor (Newburgh) did not latch positively. Similarly the soiled utility door in the Stepdown ICU unit did not latch positively.

2. On 03/23/10 at 12:00PM during the tour of the basement at Cornwall campus, it was noted that the paint shop did not have any self closure installed at the door. The room had abundant supply of paints and other liquids. It was also noted that combustibles such as cardboard boxes, cleaning cloths, and others was also stored among the hazard materials.

3. On 03/23/30 at 3:00PM, it was noted that the doors leading to Laboratory (Cornwall campus) were wide open and did not have any self closure installed at the door. This practice not only prevents the protection of the hazardous area, it also compromises the air pressure that is required to be maintained in laboratories as per NFPA 45 6-3.3. As per code 'The air pressure in the laboratory work areas shall be negative with respect to corridors and non-laboratory areas'

LSC NFPA 101, 19.3.2.1, 8.3.6,
All the above findings were shared with and brought to the attention of, escorts accompanying the surveyor at the time, such as Staff #22, Staff #28, Staff #29, Staff #30 and Staff #31.

Section 7.2.1.5.1 of NFPA 101 states that:
Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.

Based on observation and staff interview, it was determined that the facility failed to meet the above requirement and did not ensure that doors on the egress side were not equipped with locks requiring keys.

Findings include:

On 03/29/10 at 11:45AM, during a tour of the Birthing Center (postpartum suite) in Newburgh campus, it was noted that an exit door on the floor (opposite nourishment room and coat closet) leading to the stairwell was locked and required a key to be opened.
Staff #29 was asked if there was a special reason why this exit door was completely locked (unlike using an alternative such as alarmed door or delayed egress door, if required by the program) on this maternity floor. Staff #29 stated he did not know the reason why this door was locked in such arrangement.

Based on observation, it was determined that the Newburgh Campus' extension clinics did not ensure that all its emergency back up lights were operational, in good repair, and capable of supplying light for 1 1/2 hours.

Findings include:

During tour of the off-site Rehabilitation Outpatient Center (at Newburgh 9W) on 03/24/10 at 2:15PM, it was noted that an emergency battery backup light by the gym area was flickering and was not operational.
Finding was verified with Staff #28.

Based on record review and interview, the hospital did not ensure that the fire alarm system is maintained in accordance with NFPA 72.

Findings include:

1a. The fire alarm (FA) inspection report for the Newburgh Campus dated 2/8/10 does not show that notification appliances (strobes, horns etc.) were tested.
b. The FA report dated 2/8/10 in the vendor's summary test result reports that door holders throughout the facility were not tested.
c. There was no documentation available to show that issues identified in the summary FA report issued by the vendor were addressed. These issues include, but are not limited to, communication trouble signal for zones 15 and 20; and failure of primary recall for elevator #3.


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2. During the pre-opening conference on 03/22/10 at the Newburgh Campus, the facility was given a list of documents required for the survey. On 03/23/10 at 10:45AM during the tour of the Cornwall campus, surveyor asked Staff #29 about those documents, in particular referencing the fire alarm report for the Cornwall campus. Staff #29 stated that all documents were stored in the main Newburgh campus and that the surveyor will be provided with the required documents when on-site visit to Newburgh will be conducted.

On 03/29/10 at 12:00PM at Newburgh campus, Staff #29 was asked for the fire alarm reports and the surveyor was told that the documents were brought to the Cornwall campus. After exit conference of the survey on 03/29/10 at 2:45PM, surveyor was provided with one fire report for Cornwall Campus dated 02/09/10. This report was only for alarm devices on 2nd floor of the Cornwall Campus (with some ancillary space/rooms on first floor) and therefore did not provide information for the fire alarm system of the entire building/Cornwall campus.

Furthermore, the report indicated 'Mental Health' on 2nd floor and approximately 2/3 of the alarm devices were not tested due to construction in the report. During survey of the Cornwall campus, staff did not identify any space as 'Mental Health' floor/unit, thus it is unclear for which area this report reflects.

Due to this situation, it could not be verified if the facility was maintaining the fire alarm system as per NFPA 72 and what interim life safety measures the facility is utilizing to ensure safety in the areas where the alarm devices were not tested.

3. During the tour of the Cornwall campus, based on feedback given to the surveyor by Staff #29, the facility did not conduct sensitivity test on all smoke detectors installed in the facility, thus did not have sensitivity test reports for all the smoke detectors as required by NFPA 72, 7-3.2.1. This was verified by Staff #31 who stated that both campuses do not have the test reports.

Based on record review and interview the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25.

Findings include:

1. Review of the vendor's sprinkler inspection report dated 11/13/09 indicates that internal inspections for obstructions were not conducted on the sprinkler piping, the alarm valves and associated trim, and check valves at the Newburgh campus.

2. Similar finding was noted on 03/29/10 at 11:45AM during the inspection of the sprinkler report for Cornwall campus dated 02/09/10, in which no information was provided regarding the 5 year alarm/valves and internal inspection requirement. Finding was verified with Staff #29.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed conspicuously and that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10).

Findings include:

1. During the survey tour on 03/22/10 at 1:45PM of the PT/OT unit at Cornwall, it was noted that a portable fire extinguisher in the occupational therapy room was installed on the wall with its topmost portion at 64 inches above the floor. This finding was verified with Staff #22 and Staff #28

2. During the survey tour of the ICU unit on 03/26/10 at 12:45PM, it was noted that a fire extinguisher was placed in a recess cabinet in the corridor outside a patient room. No sign was posted above the fire extinguisher and a portable/movable soiled linen cart was parked nearby which partially hindered the view of the fire extinguisher. Findings were verified with Staff #36 and Staff #8.

3. Similar finding was noted on 03/23/10 at 12:00PM on Cornwall campus, 1st floor (1 west unit patient med/surg rooms) where the fire extinguisher in the corridor did not have a conspicuous sign to readily identify it from each end of the corridor. This finding was verified with Staff #22 and Staff #28.

Based on documentation review, 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:

On 03/29/10 at 12:10PM, during review of fire/smoke damper report/assessment sheet from 'Hawk Solutions' for Cornwall campus, it was noted that a damper #1-13 was found defective on 10/23/2006. No follow up report or work order was provided to verify that the defective fire damper was replaced/repaired. Finding was verified with Staff #29.

Section 8-2* of NFPA 96 states that:
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Based on document review, it was determined that the facility did not conduct semi-annual inspections on the exhaust hoods of the cooking appliances in the kitchen as required by the code.

Findings include:

On 03/29/10 at 11:50AM, Staff #29 provided the surveyor with the exhaust hood inspection reports from 2007-2009 for Cornwall campus. It was noted that the reports from 'Haight' were yearly and were dated 06/20/07, 05/30/08, and 12/07/09, respectively. Staff #29 stated there were no other semi-annual reports.

Based on observation, means of egress at the Newburgh campus are not always maintained free of impediments.

Findings include:

On 3/25/10, the exit door from the rear of the medical supply/general stores area was blocked by construction equipment and plastic sheeting. There was no doorway in the barrier erected to separate the construction from the storage area. There was no signage to provide an alternate route, or signage in front of the barrier to indicate that egress was provided on the other side.

Based on observations, the facility did not ensure that bulk oxygen storage tanks were stored in a safe manner protected from the elements, and that the storage area was clear of debris as per NFPA 99 4-3.1.2.2

Findings include:

1(a) During the tour of the Cornwall campus on 03/23/10 at 11:15AM, it was noted that an abundant amount of twigs and dried leaves was lying around the Oxygen bulk tank. Accumulation of decayed foliage and debris, such as dead decayed leaves, was noted on the entire concrete pad around and underneath the storage area of liquid oxygen tanks. Dead dried leaves are combustible and catch fire easily. Findings were verified with Staff #28 and Staff #29.
(b) Similar finding of dead leaves around the Oxygen bulk tank was found during the survey of Newburgh facility grounds. Findings were verified with Staff #31 and Staff #30.

2. During the survey of the facility grounds (Newburgh) on 02/25/10 at 3:30PM, it was noted that there was a reserve oxygen tank room (housing portable Oxygen tanks) located nearing the parking lot, outside the hospital building. This room was found open and not secured at the time of survey. The door of the room had a padlock but the padlock was not locked/closed. Furthermore, the outside fence was also not locked and no staff from engineering/facilities was present nearby. Findings were verified with Staff #31 and Staff #30.

Based on observation and staff interview it was determined that the facility did not maintain the piped in medical gas system as per NFPA 99.

Findings include:

1. On 03/23/10 11:00AM, during the tour of the Emergency Department (ED) (Cornwall campus), it was noted that the oxygen pressure reading on one of the two main medical gas alarm panel in the ED was reading as 49 PSI and other was reading 48 PSI. Staff was asked regarding the alarm/cut off points but they were not aware at what point the panels would alarm. It is to be noted that as per NFPA 99, Table 4-3.1.2.4, the standard pressure for oxygen delivery to be maintained is 50 PSI +5 and -0.

2. Similarly on 03/24/10 at 3:15PM, it was noted that in the main medical gas alarm panel at the Wound Center (Cornwall campus), oxygen reading was fluctuation as 46.7 PSI-47.7 PSI. As per Staff #34, the manufacturer's recommendation and manual specify oxygen at 50 PSI. Furthermore, it was noted that in one of the morning sessions, staff noted on the hyperbaric check list that the oxygen pressure was 49 PSI. Facility did not provide a policy for the cut off point or what if any are the side effects of not delivering oxygen at the required pressure, especially at the hyperbaric chamber.

2. On 03/29/10 at 12:30PM during the review of the medical gas report from 'Medigas' dated 06/29/09-07/02/09, it was noted that the report indicated 24 deficiencies. Out of these 24 deficiencies, corrective action follow-up was done and provided for only 5 deficiencies. No follow-up was done or provided regarding the other deficiencies.

Based on record review and interview, the facility did not ensure that humidity in the ORs is maintained as required.

The finding is:

On 3/23/10, review of the temperature and humidity logs for the ORs for the past 4 months reveals humidity levels below acceptable levels. Most days humidity was less than 20%. There was no documentation produced to indicate that corrective action was taken. The clinical nurse manager stated that these readings do not represent an accurate picture because they are taken at 5:00 AM and that during OR procedures the humidly rises to an acceptable level. The facility did not provide any documentation to show that humidity levels increased during surgery.

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 (Cornwall campus) between 03/22/10 to 03/24/10, 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 by PT/OT unit and the radiology main entrance were penetrated by ducts, pipes, conduits, cables, wires for light and other miscellaneous holes. None of the penetrations were sealed completely with an approved fire retardant material to prevent passage of smoke from one compartment to the other. This finding was verified with Staff #28 and Staff #29.

2. It was noted that the wall in the Occupational Therapy room in Cornwall campus (which was fire rated as per the floor plans) had penetrations made by conduits, fire dampers, medical gas and fiber optics, and some holes were missing fire retardants.

3. The IT room in the basement (Cornwall campus) was noted to have penetrations made by 3 silver conduits. Pipes/conduits through which blue wires were going were also noted to have no fire retardants.

A. Suites of sleeping rooms shall not exceed 5000 sq. ft.
NFPA 101 2000 18.2.5.6

Based on observation and document review, the facility did not meet the sleeping room requirements at the Newburgh campus.

Findings include:

The newly renovated sleeping suites on the 2nd, 3rd, 4th, 5th and 7th floors were greater than 10,000 sq. ft. and were not separated.


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B. Section 3-4.1-1.15, NFPA 99, requires that a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12).

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.

(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
(1) Low lubricating oil pressure
(2) Low water temperature (below those required in 3-4.1.1.9)
(3) Excessive water temperature
(4) Low fuel-when the main fuel storage tank contains less than a 3-hour operating supply.
(5) Overcrank (failed to start)
(6) Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. (110:3-5.5.2)

Based on observation, and staff interview during the survey between 03/22/10 and 03/29/10, the facility did not ensure that remote annunciators for 2 generators, at the buildings of the main Newburgh campus, are provided to operate outside of the generating room so as to indicate the alarm conditions stated under Section 3.4.1.1.15 of NFPA 99. The generator at the Cornwall campus did not have the annunciator installed in a location that is serviced by operating personnel for 24 hours.

Findings include:

1. On 03/24/10 at 3:45PM, during tour it was observed that the Cornwall campus has an remote annunciator installed in the mechanical room for its one generator on campus. Staff #28 stated that this annunciator does not have any derangement signals (as required by the code above) at a 24/7 manned station in the facility. Staff #28 stated that this mechanical room is not always occupied and that the engineering staff are out on the facility grounds performing their respective tasks.

2. On 03/25/10 at 2:30PM, during tour it was noted that the Newburgh campus maintains life support equipment to provide general anesthesia in the operating room and for ventilators in the CCU and NICU units. The facility has installed 2 generators to provide emergency power to the facility, including life support equipment, in case the normal electrical power to the facility is lost. The operating rooms are supplied by both generators. Remote annunciator panel/s outside of the generator room and an audible and visual derangement signal for alarm conditions were not provided at a constantly attended location for the conditions under 3.4.1.1.15. Findings were verified with Staff #31 and Staff #30.

C. As per NFPA 101, section 7.2.1.5.4 requires that: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Based on observation, the facility did not ensure that the exit door at the Rehabilitation Center (Newburgh-9W) meets the above requirement.

Findings include:

During the survey tour of the off-site Rehabilitation Center (at Newburgh 9W) on 03/24/10 at 1:40PM, it was noted that the rear Exit door (which is used for patient entrance also) had a thumb-twisting latching/lock installed on the door, and a lock operated by a key. When fully engaged, the thumb- twisting latching device prevents the door from opening in an obvious, one step operation required during fire/emergency evacuation. Finding was verified with Staff #32 and Staff #28.

Based on observation, it was determined that the facility did not ensure that 'No smoking' signs were installed around the fence where bulk oxygen was stored.

Findings include:

During the tour of the facility grounds between 03/22/10 and 03/29/10, it was noted that the area where bulk storage was located did not have any no smoking sign installed around the fence.
Findings were verified with Staff #28, Staff #29, Staff #30 and Staff #31.

Based on document review, it was noted that the facility did not ensure that all the elevators serving the patient care areas are certified to have firefighter recall feature installed.

Findings include:

During documentation review on 03/29/10 at 12:30 PM, it was noted that the inspection report from SimplexGrinnell, dated 03/26/10, indicated that Cornwall campus elevators number 1, 2 and 7 do not have the firefighter feature installed.