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Based on observations and interview, the facility did not ensure that buildings containing Health Care occupancies that were of Type II (000) unprotected, non-combustible construction were no more than two (2) stories high and provided with complete automatic sprinkler protection.

Findings include:

(a) On 05/22/2015 at 12:33 PM, unprotected steel joists were noted above a non-fire resistance rated suspended ceiling assembly in a 6th floor corridor (vicinity of elevator cabs 5, 6 and 7). As per concurrent interview with the facility ' s Director of Engineering, the facility has sprinkler protection above and below this suspended ceiling assembly as a means of providing equivalent protection to that of the required fire resistive construction.

Prior to the exit, the Director of Engineering could not provide evidence of a waiver.


(b). On the morning of 05/26/2015, unprotected steel joists were noted above a non-fire resistance rated suspended ceiling assembly in a 4th floor corridor (vicinity of elevator cabs 5, 6 and 7 and the entrance to the Newborn Intensive Care Unit (NICU) suite). In addition, numerous holes and unsealed penetrations were noted in a fire resistance rated ceiling assembly in the 4th floor NICU suite and maternity units (e.g., the visitor toilet room by room 444).

(c). On the afternoon of 05/26/2015, unprotected steel joists and steel beams were noted in a basement corridor (beneath the radiology unit) and in a basement housekeeping supply storage room.

It should be noted that observations made during the course of the survey on 05/22/15, 05/26/2015, and 05/27/2015 revealed that much of this 9 story hospital building is not provided with sprinkler protection.

42CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.1.6, Table 19.1.6.2

Based on observations and staff interviews during the survey, the facility did not ensure that corridor walls in smoke compartments that were not provided with a complete automatic sprinkler system (e.g., units lacked complete sprinkler protection), were constructed to provide at least a ½ -hour fire resistance rating.

Findings include:


(a). On 05/22/2015 at 1:50 PM, an unsealed cable penetration was found in a corridor wall of the 5th Floor of the hospital (vicinity of 5J Room 501). As per concurrent interview with the facility ' s Director of Engineering acknowledged the finding.

(b). On 05/22/2015 at 2:00 PM, an unsealed cable penetration was found in a corridor wall of the 5th Floor of the hospital (vicinity of 5J electrical room).

(c). On 05/26/2015 at 8:34 AM, an unsealed cable penetration was found in a corridor wall of the 4th Floor of the hospital (vicinity of the janitors closet and room 403).

(d). On 05/26/2015 at 9:19 AM, an unsealed cable penetration was found in a corridor wall of the 4th Floor of the hospital (vicinity of room 440 and room 441).

(e). On the morning of 05/26/2015, an unsealed cable penetration and two small holes were found in a corridor wall of the 4th Floor of the hospital (vicinity of Labor/Delivery Room 5) and an unsealed cable penetration was noted in a corridor wall (vicinity of Labor/Delivery Room 3) .

(f). On 5/26/15 between 10:30 AM- 11:00 AM, unsealed conduit and wire penetrations and holes were noted in the corridor wall between the Pantry and room 301 on the 3 North unit.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.1, 19.3.6.2.1

Based on observations and interviews, the facility did not ensure that vertical electrical penetrations were properly sealed.

The findings were:

(a). On 05/22/2015 at 12:04 PM, an unprotected opening to a vertical electrical wiring chase in a 9th floor West Wing Mechanical Room (vicinity of Stair H) was found. As per concurrent interview with the facility's Director of Engineering, he acknowledged the finding.

(b). On 05/26/2015 between 2:18 and 2:20 PM, multiple holes were noted in enclosure walls of a basement level accessory stair that connects the basement to the 1st floor (Stair "E"). In addition, the self-closing device on this door did not work properly and needs to be adjusted so that the door latches in the closed position.

42CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.1.1, 8.2.5.6

Based on observations and interview, the facility did not ensure that all required smoke barrier walls were constructed to provide at least a ½-hour fire resistance rating.


Findings:


Required smoke barrier walls were not constructed to provide at least a ½-hour fire resistance rating. Reference is made to small holes and gaps in smoke barrier walls and building service equipment penetrations of smoke barrier walls that were either unsealed or not sealed with a UL Listed Through Penetration Firestop System.

Examples:


(a). On 05/22/2015 at 11:40 AM, two (2) unsealed cable penetrations were found in a 8th Floor 2-hour fire resistance rated combination fire barrier/smoke barrier wall above cross-corridor door in the vicinity of GI suite changing room and clean storage room. In addition, a duct penetration containing a motorized fire/smoke damper that penetrates the above-referenced wall was found to have been improperly sealed with fire stopping materials (e.g. firestopping caulk) that could expand when exposed to the heat of a fire and could potentially impinge upon (crush) the duct, hampering the operation of the damper. As per concurrent interview with the facility's Director of Engineering, he aknowledged the finding.



(b). On 05/22/2015 at 1:40 PM, a duct penetration containing a motorized fire/smoke damper that penetrates a 5th floor smoke barrier wall (vicinity of Stair " J " and Room 5J25) was found to have been improperly sealed with fire stopping materials (e.g. firestopping caulk) that could expand when exposed to the heat of a fire and could potentially impinge upon (crush) the duct, hampering the operation of the damper. As per concurrent interview with the facility's Director of Engineering, he aknowledged the finding.

(c). On 05/26/2015 at 8:44 AM, an unsealed cable penetration and a partially sealed conduit penetration were noted on one side of 4th floor smoke barrier wall (above cross-corridor doors near Room 410).


(d). On 05/26/2015 at 9:10 AM, a pipe was found to have been improperly incorporated in the construction of a 4th Floor 2-hour fire resistance rated combination fire barrier/smoke barrier wall inside of Exit Stair " J " .


(e). On 05/26/2015 at 9:54 AM, an unsealed cable penetration was found in a 4th floor smoke barrier wall (vicinity of entrance door to the NICU suite and an elevator lobby).


(f). On 05/26/2015 at 9:54 AM, an unsealed cable penetration was found in a 4th floor smoke barrier wall (vicinity of cross corridor door near the well-baby nursery).


42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.2.3, 8.3.3

Based on observation and interview during the survey, the facility failed to ensure that smoke barrier doors were provided with self-closing devices. This was noted for the Pre-Surgical Office door on the 3rd floor.

The findings are:

On 05/26/2015 at approximately 9:00AM, the door to the Pre-Surgical Office that was part of the smoke barrier, as indicated by the facility ' s Life Safety Drawings, was not provided with a self-closing devices.

In an interview on 05/26/2015 at approximately 9:00AM, with the facility's Director of Engineering, he acknowledged the finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.6

Based on observation and interview during the survey, the facility failed to ensure that hazardous areas shall be protected with a ¾ hour fire-rated door, protected by a sprinkler system and provided with self-closing doors. This was noted on the 3rd floor in the Operating Rooms (OR ' s) and the Basement.

The findings are:

(a). On 05/26/2015 and 05/27/2015 between 8:00am- 3:00pm, hazardous areas were not protected with a ¾ hour fire-rated door, protected by a sprinkler system, and provided with self-closing doors. Examples are:

1) OR#1 was noted converted into a storage room. The room lacked sprinkler coverage and the door was noted with a plain glass vision panel. There was no fire-rating etched on the glass or on the frame.
2) OR#9 was noted converted into a storage room. The room lacked sprinkler coverage.
3) The door to the Clean Linen Storage Room in the Basement was observed lacking a self-closing device.

In an interview on 5/26/15 at approximately 9:40 AM, the Engineering worker stated that the OR ' s were converted to storage rooms approximately 3 years ago. When the facility converted the Operating Rooms to storage rooms they failed to provide all of the fire protection features that a storage room would require (e.g., sprinkler protection, 1-hour fire resistance rated enclosure, and self-closing doors).

(b). On 05/26/2015 at 11:10 AM, a former hematology laboratory on the 2nd floor that had been converted into a storage room was found to lack required self-closing devices on the door to this room. As per concurrent interview with the facility's Director of Engineering, he acknowledged the finding. When the facility converted the laboratory to a storage room they failed to provide all of the fire protection features that a storage room would require (e.g., a self-closing door).



(c). On 05/26/2015 at 12:31 PM, the door to the Gift Shop Storage Room (vicinity of the 2nd floor main lobby) was found to lack a self-closing device. As per concurrent interview with the facility's Director of Engineering, he acknowledged the finding.


42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.2.1, 8.4

Based on observation and interview during the survey, the facility failed to ensure that exit enclosures (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour. This was noted on the 1st and 3rd floor.

The findings are:

On 05/26/2015 between 8:00 AM- 3:00 PM, the facility failed to ensure that exit enclosures and exit passageways were enclosed with construction having a fire resistance rating for at least two hours and provide protection against fire or smoke from other parts of the building. Examples include:

1) The top of wall joint of Stair I within the Intensive Care Unit (ICU) on the 3rd floor was noted sealed with joint compound and not a UL-listed fire-stopping material.
2) Partially sealed wire penetrations were noted above the door to Stair K and unsealed wire penetrations within Stair K were noted above the door to the Operating Room on the 3rd floor.
3) An insulated pipe penetration sealed with joint compound and not a UL-listed fire-stopping material was noted in Stair A in the vicinity of the Elevator Lobby on the 3rd floor.
4) Unsealed wire penetrations and holes were noted above the ceiling in the 1st floor exit passageway in the vicinity of the Radiology Nurse Office.
5) Unsealed top of the wall joint and an unsealed beam penetration were noted above the door to Stair E on the 1st floor.
6) The door to the ER (Emergency Room) office was provided with a self-closing device that holds the door in the open position and not tied into the fire alarm system. This door is part of an exit passageway on the 1st floor.
7) An unsealed conduit penetration was noted above the cross-corridor doors in the vicinity of the Physical Therapy (PT) waiting room. These doors are part of an exit passageway on the 1st floor.

In an interview on 05/26/2015 at approximately 12:40 PM, the facility's Senior Director of Engineering, he acknowledged the finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.1.3.2, 8.2.5.2, 8.2.5.4, 19.3.1.1

1. Based on observation and staff interview, the facility did not ensure that openings into exit enclosures were limited to those necessary for access to the enclosure from normally occupied spaces and corridors, and for egress from the enclosure.

Findings:

(a). On 05/22/2015 at 11:06 AM, a door from a rooftop elevator room (i.e., elevator machine room for Elevator Cabs 5-6-7)) was found to open directly into an exit enclosure (Exit Stair "D"). This machine room is not provided with sprinkler protection. As per concurrent interview with the Facility's Director of Engineering, he acknowledged the finding.

(b) On 05/22/2015 at 11:47 AM, a door from a rooftop elevator room (i.e., elevator machine room for Elevator Cabs 1-2-3-4)) was found to open directly into an exit enclosure (Exit Stair "H"). This machine room is not provided with sprinkler protection.

(c). On 05/22/2015 at 12:05 PM, a door from 9th floor machine room was found to open directly into an exit enclosure (Exit Stair "H"). This machine room is not provided with sprinkler protection.

(d). On 05/22/2015 at 1:19 PM, a door from 5th floor machine room was found to open directly into an exit enclosure (Exit Stair "K"). This machine room is not provided with sprinkler protection.

(e). On 05/27/2015 at 8:30 AM, doors from 9th floor machine room and communication equipment rooms were found to open directly into an exit enclosure (Exit Stair "G").


42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.1, 19.2.2.3, 7.2.2.1, 7.1.3.2.1 (d)

2. Based on observations and interviews during the survey, the facility failed to ensure that exit stairs were free of prohibited penetrations of the exit stair enclosure as well as being free of any impediments that have the potential to interfere with the use of the exit.

Findings were:

(a). On 05/22/2015 at 11:15 AM, electrical cables that do not serve any functions within Exit Stair " B " were found to have been improperly run from a rooftop elevator machine room into the exit stair enclosure of exit stair " B " . As per concurrent interview with the facility ' s safety director, he acknowledged the finding.


(b). On 05/22/2015 at 11:58 AM, electrical cables that serve rooftop satellite TV dishes were found to have been improperly run into the exit stair enclosure of exit stair " H " . As per concurrent interview with the facility ' s Director of Engineering, he acknowledged the finding.

(c). On 05/27/2015 at 8:30 AM, the fire door that separates a 9th floor machine room from exit stair " G " was found to have been improperly tied open. In addition, bags of tools were found to be improperly stored unattended on a 9th floor landing in exit stair " G " and a rolling work cart and ladder were improperly stored in the 8th floor landing of exit stair "G " . As per concurrent interview with the facility ' s Director of Engineering, he acknowledged the finding.

(d). On 05/27/2015 at 8:33 AM, the treads of steps between the 9th floor and the 8th floor landings in exit stair " G " were noted to be in disrepair and could be a tripping hazard to building occupants.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.2.3, 7.2.2.1, 7.1.3.2.1 (e), 7.1.3.2.3

Based on observation and interview, the facility failed to provide emergency illumination for not less than 1½ hours in the event of failure of normal lighting.

The findings are:

(a). On 05/22/2015 at 11:22 AM, emergency illumination for not less than 1½ hours in the event of failure of normal lighting was not provided for the rooftop means of egress between the exit door from the 9th floor Switchboard/Communications Suite to the door to exit stair " D " . As per concurrent interview with the facility's Director of Engineering, he acknowledged the finding.

(b) On 05/26/2015 between 12:00 PM- 1:00 PM, the facility failed to provide emergency illumination for not less than 1½ hours in the event of failure of normal lighting. Examples are:

1) Emergency lighting was not provided along the egress path from exit Stair G to the public way in the vicinity of the Employee ' s Entrance.

In an interview on 05/2720/15 at approximately 11:25 AM, the electrician stated that the wall pack lighting units in the vicinity of the Employee ' s Entrance were connected to normal power only.

2) Exit discharge lights in the vicinity of the CT trailer were noted operable by light switches. Use of switch control can leave this means of egress in darkness, hampering the use of this means of egress in an emergency.


In an interview on 05/26/2015 at approximately 12:47 PM, the Senior Director of Engineering, acknowledged the finding.


(c). On 05/26/2015 at 1:28 PM, emergency lighting in the exit access corridor by the rear exit from the 2nd floor Breast Health unit were operable by light switches. Use of switch control can leave this means of egress in darkness, hampering the use of this means of egress in an emergency.


42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.9.2.1, 7.9.2.2

Based on observation and interview during the survey, the facility failed to ensure the protection of all persons in the event of a fire and for their evacuation to areas of refuge. Reference is made to the smoke barrier in the vicinity of the 3rd floor Pre-Surgical Office that is arranged so that the body of the Pre-Surgical Office is in one smoke compartment but the only exit from this room opens into the adjacent smoke compartment.

The findings are:

On 05/26/2015 at approximately 9:00 AM, the door to the Pre-Surgical Office was noted to be part of the smoke barrier, as indicated by the facility' s Life Safety Drawings. The body of the office was in one smoke compartment but the only exit from the room opens into the adjacent smoke compartment. This arrangement would require the evacuation of this room in the event of a fire in either smoke compartment.

In an interview on 05/27/2015 at approximately 9:55 AM, the Director of Environmental Health and Safety acknowledged this finding and stated that the current fire plan does not address this special circumstance.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.7.1.1, 19.7.2.2

1. Based on observation and interview during the survey, the facility failed to ensure that required automatic sprinkler systems were continuously maintained in reliable operating condition. This was noted on the 3rd & 1st floors and the Basement.

The findings are:

(a). On 05/22/2015 at 11:14 AM, a sprinkler in the 9th floor landing of stair " B " was noted to have a foreign material (e.g., paint) on it.

On 05/26/2015 to 05/27/2015 between 8:00 AM- 3:00 PM, the automatic sprinkler system was noted to not being continuously maintained in reliable operating condition. Examples include but are not limited to:

1) External loads were noted hanging from sprinkler pipes in the following areas:
a. Multiple ceiling grids and light fixtures on the 3 North unit.
b. Wiring connected to sprinkler piping in the Basement East Main Storage Room
c. Wiring connected to sprinkler piping in the 2nd floor main lobby of the hospital building

2) Painted or loaded sprinkler heads or escutcheons in the following areas:
a. Staff bathroom within the corridor to the 3 North unit- spackle on a pendent sprinkler head.
b. 1st floor main lobby- two painted concealed sprinkler escutcheon cover plates.
c. Basement- painted upright sprinkler heads in the Sump Pump Room, Housekeeping Storage Room and Laundry Room.
d. Basement painted upright sprinkler in the East main Storage Room.
e. Two (2) concealed sprinkler escutcheon cover plates in the suspended ceiling of 2nd floor main lobby of the hospital building had been painted.


3). Sprinkler support brackets not maintained in the following areas:
(a) Three (3) sprinkler piping support hangers that were in disrepair in a basement housekeeping storage room.
(b). Bailing wire was improperly used as a sprinkler piping support hanger above the suspended ceiling in the 2nd floor main lobby of the hospital building.

During an interview on 5/27/15 at approximately 8:08 AM, the Director of Engineering acknowledged this finding

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.7.5, 1998 NFPA 25: 2-2.1.1



2. Based on observation and interview during the survey, the facility failed to ensure that each sprinkler system control valve was identified and each have a sign indicating the system or portion of the system it controls. This was noted on the 2nd floor and the Basement.

The findings are:

On 05/26/2015 between 8:00 AM- 3:00 PM, control valves for the sprinkler system were noted to be lacking signs identifying the system or portion of the system it controls.
Examples include but are not limited to:

1) Above the drop ceiling within Stair A at the 2nd floor landing.
2) Basement corridor in the vicinity of Stair A.
3) Basement corridor outside of the Fire Pump Room.
4) Basement Fire Pump Room.
5) Basement corridor outside of the Linen Chute Room.
6) Basement corridor in the Center Elevator Lobby.

In an interview on 05/26/2015 at approximately 1:43 PM, the Senior Director of Engineering, acknowledged the findings.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.7.5, 1998 NFPA 25: 9-3.2

1. Based on observations and staff interviews, the facility failed to ensure that portable fire extinguishers were installed in accordance with the requirements found in NFPA 10, Standard for Portable Fire Extinguishers.

The findings were:

(a). On 05/22/2015 at 2:20 PM, a fire extinguisher that was stored in a recessed cabinet in a wall of the 5th floor North Diabetes Educational Conference Center was noted to lack a required identification sign. When the physical location of a portable fire extinguisher is not readily visible, another form of location identification (e.g., signage) is required.

(b). On 05/22/2015 at 2:28 PM, a fire extinguisher that was stored in a recessed cabinet in a wall of the 5th floor (near entrance to breezeway by the 5 Joyce wing) was noted to lack a required identification sign. When the physical location of a portable fire extinguisher is not readily visible, another form of location identification (e.g., signage) is required.

As per concurrent interviews with the facility ' s Director of Safety, acknowledged this finding.


42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.6, 9.7.4.1, NFPA 10-1998 Standard for Portable Fire Extinguishers: 1-6.10, 1-6.3, 1-6.6

2. Based on observations and staff interview during the survey, the facility failed to ensure that portable fire extinguishers were maintained and tested in accordance with the requirements found in NFPA 10, Standard for Portable Fire Extinguishers.

The finding was:

On 05/26/2015 at 12:47 PM, a portable fire extinguisher located in a 2nd floor Central Sterile area cart washer equipment room was found to have last been hydrostatically tested in January, 1999, the pressure gauge indicated that the fire extinguisher was overcharged, and there was no monthly inspection tag on the fire extinguisher. As per concurrent interview with the facility ' s Director of Engineering, he acknowledged the finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.6, 9.7.4.1, NFPA 10-1998 Standard for Portable Fire Extinguishers: 4-3.1, 4-4.1, 4-4.4, 5-1. Table 5-2

Based on observations and staff interview during the survey, the facility failed to ensure that required placards identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system were conspicuously placed near each portable fire extinguisher in Cooking Areas.

The findings are:

On 5/26/15 at approximately 11:05 AM, the facility was found lacking the required placard (sign) identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system near the portable " K " type fire extinguishers in the 3rd floor Cafeteria. The required placard shall state " WARNING: In case of appliance fire use this extinguisher after fixed suppression system has been used " .

In an interview on 5/26/15 at approximately 11:05 AM, the Senior Director of Engineering acknowledged this finding.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96-1998 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 7-2.1.1

1. Based on observations and staff interviews during the survey, the facility did not ensure that electrical fixtures in oxygen storage locations were mounted at least 60- inches above the finished floor as a precaution against their physical damage.

The findings were:

(a). On 05/22/2015 at 1:43 PM, an electrical light switch in a compressed medical gas (e.g., oxygen) cylinder storage room on the 5th floor of the hospital (vicinity the nurse ' s station in the 5J unit) was installed at a height of 50-inches above the floor.

(b). On 05/26/2015 at 9:28 AM, an electrical light switch in a compressed medical gas (e.g., oxygen) cylinder storage room on the 4th floor of the hospital was installed at a height of 50-inches above the floor.


(c). On 05/26/2015 at 11:20 AM, an electrical light switch which had a damaged plastic cover plate in the 2nd floor pathology lab (located next to carbon dioxide tanks/manifold system) was installed at a height of only 50-inches above the finish floor.

(d). On 05/26/2015 at 11:25 AM, an electrical light switch in a compressed medical gas (e.g., nitrogen and nitrous oxide) cylinder storage/manifold room on the 2nd floor of the hospital was installed at a height of 47-inches above the floor.


As per concurrent interviews with the facility ' s Director of Engineering, he acknowledged these findings.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 4-3.1.1.2 (a) (4), (c)


2. Based on observations and staff interview, the facility did not ensure that vehicles did not park any closer than 10-feet from exposed piping at the bulk oxygen storage location or that NO PARKING signs were properly installed or maintained.

The finding was:

On 05/26/2015 at 1:37 PM, a SUV (NY license # CUH-4814) was found to have been parked only 80-inches from exposed piping at the hospital ' s bulk oxygen storage location (vicinity of the north side of the enclosure). Parked vehicles are required to be at least 10-feet (120-inches) from any exposed piping. In addition, there was no "NO PARKING" sign posted on the north side of the bulk oxygen storage location and the writing on the "NO PARKING" sign on the south side of the enclosure was so faded that it was almost illegible. As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.2.4, NFPA 99-1999, Standard for Health Care Facilities: 4-3.1.1.2 (b) (1), NFPA 50-1996, Standard for Bulk Oxygen Systems at Consumer Sites: 2-2.12

Based on observation and interview during the survey, the facility failed to ensure that penetrations of smoke barriers by ducts are protected in accordance with 8.3.5 in that smoke dampers were noted lacking within the duct above the smoke barrier doors between the Intensive Care Unit (ICU) and Recovery on the 3rd floor.

The findings are:

On 5/26/15 at approximately 8:51 AM, a duct penetration above the smoke barrier doors between ICU and Recovery on the 3rd floor was noted lacking a smoke damper.

In an interview on 5/26/15 at approximately 8:51 AM, the Senior Director of Engineering acknowledged this finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3.5.1

1. Based on observation and interview during the survey, the facility did not ensure that the safety of the building containing a healthcare occupancy was not compromised by the placement of non-fire resistance rated combustible structures less than 10-feet from unprotected windows.

Finding:

On 05/22/2015 at 10:50 AM, a Type (V) (000) construction type wooden structure (a connecting corridor that attaches the main hospital to a trailer containing a CT scanner (the " CT Scanner" Building) was found to have been installed approximately 8-feet from two unprotected windows in the main hospital building. A 90-minute fire door and 2-hour fire resistance rated exterior wall separate the main hospital building from the wooden accessory structure. The connecting structure was found to have: a hardwired fire alarm system, a hardwired emergency lighting system, hardwired exit directional signage, portable fire extinguishers, and that dimensional lumber used in the construction had been treated with INSL-X brand intumescent fire retardant paint, and that Pyroguard brand fire retardant plywood was used for wall and roof sheathing. The only fire safety concern is the window openings.

As per concurrent interviews with Facility's Director of Engineering and Safety Officer, the facility had not obtained required New York State Department of Health approval of this project at the time of the inspection.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.1.6.2, NFPA 80, Standard for Fire Doors and Fire Windows, NFPA 80A, Recommended Practice for Protection of Buildings from Exterior Fire Exposures


2. Based on observations and interviews, the facility failed to ensure that buildings that containing atriums were fully sprinklered and the facility failed to ensure that other requirements for buildings containing atriums were met.

Findings:

Observations on the afternoon of 05/27/2015 revealed that the building had a two (2) level Atrium between the 2nd and 3rd floor and that the Atrium was not constructed in accordance with NFPA 101-2000: 8.2.5.6.

(a) The entire building is not provided with sprinkler protection. For example, portions of the 2nd floor (e.g., the breast health unit) and 3rd floor (e.g., the ambulatory surgery unit recovery area) that are open to the atrium, as well of portions of the atrium itself lack sprinkler protection.

Sprinklers were found to be missing in 4th floor maternity unit electrical closet (it was also noted that this closet was not enclosed by at least 2-hour fire barriers, so it would not meet the listed exception for not having a sprinkler), and air handling equipment room, 2nd floor administrative suite, 7th floor on-call rooms (e.g., Room 705W), an rooftop machine rooms. Some of the exit stairs lacked sprinkler protection, and the 2nd floor pharmacy " Forma " freezer storage alcove lacked sprinkler protection.

(b). On the afternoon of 05/26/2015, it was noted that the fire alarm panel in the 2nd floor elevator lobby of the atrium identified that this area was provided with a "smoke purge" capability.

As per interview with the facility ' s Director of Engineering on 05/26/2015 at approximately 1:20 PM, he acknowledged this finding and said that he was not sure if the smoke purge system was operational.

On the morning of 05/27/2015, facility staff were unable to provide any evidence that the smoke purge system was being maintained and tested nor could they provide a written policy and procedure for the maintenance and testing of this system. It should be noted that the atrium smoke control system must be able to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 ft (1.85 m) above the highest floor level of exit access open to the atrium for a period equal to 1.5 times the calculated egress time or 20 minutes, whichever is greater. The engineered smoke control system must be is independently activated by each of the following:
a. The required automatic sprinkler system
b. Manual controls that are readily accessible to the fire department


42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 8.2.5.6




3. Based on observations and staff interview during the recertification survey, the facility failed to ensure that the integrity of fire barriers were maintained.

The findings were:

(a). On 05/22/2015 at 11:44 AM, two unsealed cable penetrations were found above the cross-corridor 2-hour fire resistance rated fire barrier door between the 9th floor 1980 ' s and 1960 ' s wings. As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding.

(b). On 05/22/2015 at 12:20 PM, an unsealed cable penetration was found above the cross-corridor 2-hour fire resistance rated fire barrier door between the 7th floor 1980 ' s and 1960 ' s wings. As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding.

(c). On 05/26/2015 at 9:30 AM, an unsealed cable penetration was found above the cross-corridor 2-hour fire resistance rated fire barrier door vicinity of the entrance to the 4th floor maternity wing (vicinity of the visitor toilet room).

(d). on 05/26/2015 at 1:58 PM in the basement Red Bag storage room, the actuator arm on a motorized smoke damper in the fire barrier in this room was noted to be in disrepair and that the damper would not be able to function.

(e). On 05/26/2015 at 2:44 PM, a plumbing penetration of a 2-hour fire resistance rated barrier wall that separates the basement of the hospital from the adjacent nursing home building was found to have been improperly sealed with an unapproved, non-fire resistance rated material (e.g., polyurethane expansion foam) on one side of the fire barrier wall.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.1.1.4.1, 8.2


4. Based on observation and staff interview during the survey, the Facility failed to ensure that the arrangements of all means of egress in the hospital were in accordance with NFPA 101-2000: 19.2.5.

The finding was:

On morning of 05/26/2015, it was noted that a designated means of exit access from a 4th floor maternity unit elevator lobby was directed through intervening rooms or spaces (e.g., Neonatal Intensive Care Unit suite). Exit access corridors are required to provide access to exits without passing through any intervening rooms or spaces other than corridors or lobbies. As per interview with the Facility's Director of Engineering on 05/26/2015 at 9:55 AM, he acknowledged this finding and said that he would inform the hospital ' s administration of this issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.5.9, 7.4, 7.5

5. Based on observations and staff interview during the survey, the facility failed to ensure that doors in a means of egress were operable with not more than one releasing operation.

The finding was:

On 05/26/2015 at 12:34 PM., to was noted that the exit door from the 2nd floor gift shop was provided with two different door latching mechanisms on the egress side of the door when only one is permitted. As per concurrent interview with the facility ' s Director of Environmental health and safety, he acknowledged this finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.2.1.5.4

6. Based on record review and staff interview, the facility did not ensure that Ambulatory health care facilities were separated from other tenants and occupancies by walls having not less than a 1-hour fire resistance rating.

The finding was:

On 05/26/2015 at 1:35 PM, review of life safety plan for the 2nd floor of the hospital (drawing number MHS-NRH-TW-02 dated 02-11-2015) indicated that an existing tenant (a chronic dialysis clinic that is an Existing Ambulatory Healthcare Occupancy) was not separated by at least 1-hour fire barriers from adjacent areas of the hospital (e.g., vicinity of the women ' s breast health clinic. As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding and could not provide evidence that the required separation existed prior to the exit.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 21.3.7.1

1. Based on observations and record (i.e., pane board schedule) reviews, and staff interviews during the survey, the hospital was not provided with a Type 1 Essential Electrical System that was divided into separate critical branch, life safety branch, and equipment systems in accordance with NFPA 99. In addition, the facility failed to ensure that normal service wiring was separated from emergency service wiring. These deficiencies were noted in existing areas of this hospital.

The findings were:


(a). On 05/26/2015 at 8:46 AM, review of the emergency power panel directory for panel " EA " in the 4th floor of the hospital was found to serve both Emergency System-Life Safety Branch loads (e.g., exit signs, medical gas alarm, hall lights) and Emergency System-Critical Branch loads (e.g. nurse call system, Pyxis machine and hall receptacles, T.V. power supply).

As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding and said that he would notify hospital administration concerning this condition.


(b). On the morning of 05/26/2015, review of the emergency power panel directory for panel " EL-4 " in the 4th floor of the hospital was found to serve both Emergency System-Life Safety Branch loads (e.g., exit lights, exit stair lighting) and Emergency System-Critical Branch loads (e.g. hall receptacles, nursery task lighting, infant abduction system).

(c). On the morning of 05/26/2015, review of the emergency power panel directory for panel " S-E " in the 4th floor of the hospital was found to serve both Emergency System-Life Safety Branch loads (e.g., exit lights in nursery area, medical gas alarm) and Emergency System-Critical Branch loads (e.g. Neonatal Intensive Care Unit (NICU) and other patient room receptacles).

(d) On the morning of 05/26/2015, review of the emergency power panel directory for panel " 3-N " in the 3rd floor of the hospital was found to serve both Emergency System-Life Safety Branch loads (e.g., medical gas alarm, corridor lights) and Emergency System-Critical Branch loads (e.g. treatment room task lighting, treatment room receptacles, nurse call system).

(e). On the morning of 05/26/2015, review of the emergency power panel directory for panel " S-H " in the 1st floor of the hospital was found to serve both Emergency System-Life Safety Branch loads (e.g., exit lights) and Emergency System-Critical Branch loads (e.g. corridor and patient room receptacles, nurse call system).

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9

1. Based on observations and staff interview during the survey, the facility failed to ensure that all panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors in accordance with the requirements of NFPA 70, National Electrical Code.
The findings include, but are not limited to, the following:

(a). On 05/22/2015 at 11:08 AM, it was observed in the rooftop penthouse next to the elevator machine room by stair " B " that an electrical panel (panel " 2093 " ) lacked any panel direct function identification directory.

As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding.

(b). On 05/22/2015 at 2:05 PM, it was observed in the 5th floor Joyce wing that an electrical panel (panel " 5 DEN " ) lacked any panel direct function identification directory.

(c). On 05/26/2015 at 11:20 AM, a 2nd floor emergency power panel located in the corridor near the entrance to the main laboratory suite was observed to lack any panel direct function identification directory.

(d). On 05/26/2015 at 1:05 PM, a 2nd floor emergency power panel (e.g., labeled " critical branch " located in the corridor near the entrance to chronic dialysis clinic was noted to lack any panel direct function identification directory.



42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13

2. Based on observations and staff interview during the survey, the facility failed to ensure that electrical wiring was installed in a neat and workman like manner or maintained in good repair, and that unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment were provided in accordance with the requirements of NFPA 70, National Electrical Code.
Findings include, but not limited to, the following:

(a). On 05/22/2015 at 1:53 PM, an approximately 4-inch by 4-inch electrical junction box (located above the suspended ceiling in the 5th floor breezeway between the Joyce wing and the East wing) lacked a cover plate on one side of the box.

(b). On 05/26/2015 at 11:24 AM, an approximately 4-inch by 4-inch electrical junction box was in the compressed medical gas (e.g., nitrogen and nitrous oxide) cylinder storage/manifold room on the 2nd floor of the hospital lacked a cover plate on one side of the box.

(c). On 05/26/2015 at 2:11 PM, several open (e.g., uncovered) junction boxes and electrical raceways were noted in a basement housekeeping storage room.

(d). On the morning of 05/27/2015, in four (4) separate instances, electrical wiring (e.g., BX cable) above the suspended ceiling in the 2nd floor main lobby of the hospital were improperly spliced together and were not properly enclosed in an approved electrical junction box.

As per concurrent interviews with the facility ' s Director of Engineering, he acknowledged this finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12

3. Based on observations and staff interviews, the facility failed to ensure that flexible cords and cables are not used as a substitute for the fixed wiring of a structure.
The finding was:
On 05/26/2015 at 11:13 AM in the microbiology laboratory unit on the 2nd floor of the hospital, an extension cord found to be improperly used to supply power to a microscope. As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding.
NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3, 400-8

4. Based on observation, record reviews, and staff interviews, the facility failed to ensure that electrical equipment was tested in accordance with manufacturer's instructions and their listing.

The finding was:

On 05/26/2015 at 1:26 PM, a duplex ground fault circuit interrupter (GFCI) electrical receptacle in the 2nd floor women ' s breast health clinic toilet room (near the elevator lobby) was found to be labeled by the manufacturer " TEST MONTHLY " . As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding and said that he was not aware that he was required to test these receptacles on a monthly basis and had no testing records for these devices.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3 (b)

1. Based on observation and interview during the survey, the facility failed to ensure that alcohol based hand sanitizers are not used in carpeted areas that lack sprinkler protection.

The finding was:

On 05/26/2015 at 1:33 PM, a dispenser containing 62% ethyl alcohol hand sanitizer was noted in the 2nd floor Breast Health unit changing area and in procedure room #2. Both of these rooms have carpeting and lack required sprinkler protection. As per concurrent interview with the facility ' s Director of Environmental Health and Safety, he acknowledged this finding and said that he would inform the hospital ' s administration of this issue.


CFR, 482.41

2. Based on observation and interview during the survey, the facility failed to ensure that not more than 10 gallons of alcohol based hand sanitizer are stored in a single smoke compartment outside a storage cabinet. This was noted in the Housekeeping Storage Room in the Basement.

The findings are:

On 05/26/2015 at approximately 2:10 PM, approximately 118 gallons of alcohol based hand sanitizer (Ethyl Alcohol 62%) was noted being stored in the Housekeeping Storage Room in the Basement and not within a fire resistance rated storage cabinet. In addition, it was noted that the storage room itself did not meet lack a fire resistance rating due to multiple unsealed wire and conduit penetrations in enclosure walls.

In an interview on 05/26/2015 at approximately 2:10 PM, the Director of Environmental Health and Safety acknowledged this finding.

CFR, 482.41, NFPA 101-2000 Life Safety Code: 4.6.1.2, 8.4.1.1

Based on observations and interview, the facility did not ensure that buildings containing Health Care occupancies that were of Type II (000) unprotected, non-combustible construction were no more than two (2) stories high and provided with complete automatic sprinkler protection.

Findings include:

(a) On 05/22/2015 at 12:33 PM, unprotected steel joists were noted above a non-fire resistance rated suspended ceiling assembly in a 6th floor corridor (vicinity of elevator cabs 5, 6 and 7). As per concurrent interview with the facility ' s Director of Engineering, the facility has sprinkler protection above and below this suspended ceiling assembly as a means of providing equivalent protection to that of the required fire resistive construction.

Prior to the exit, the Director of Engineering could not provide evidence of a waiver.


(b). On the morning of 05/26/2015, unprotected steel joists were noted above a non-fire resistance rated suspended ceiling assembly in a 4th floor corridor (vicinity of elevator cabs 5, 6 and 7 and the entrance to the Newborn Intensive Care Unit (NICU) suite). In addition, numerous holes and unsealed penetrations were noted in a fire resistance rated ceiling assembly in the 4th floor NICU suite and maternity units (e.g., the visitor toilet room by room 444).

(c). On the afternoon of 05/26/2015, unprotected steel joists and steel beams were noted in a basement corridor (beneath the radiology unit) and in a basement housekeeping supply storage room.

It should be noted that observations made during the course of the survey on 05/22/15, 05/26/2015, and 05/27/2015 revealed that much of this 9 story hospital building is not provided with sprinkler protection.

42CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.1.6, Table 19.1.6.2

Based on observations and staff interviews during the survey, the facility did not ensure that corridor walls in smoke compartments that were not provided with a complete automatic sprinkler system (e.g., units lacked complete sprinkler protection), were constructed to provide at least a ½ -hour fire resistance rating.

Findings include:


(a). On 05/22/2015 at 1:50 PM, an unsealed cable penetration was found in a corridor wall of the 5th Floor of the hospital (vicinity of 5J Room 501). As per concurrent interview with the facility ' s Director of Engineering acknowledged the finding.

(b). On 05/22/2015 at 2:00 PM, an unsealed cable penetration was found in a corridor wall of the 5th Floor of the hospital (vicinity of 5J electrical room).

(c). On 05/26/2015 at 8:34 AM, an unsealed cable penetration was found in a corridor wall of the 4th Floor of the hospital (vicinity of the janitors closet and room 403).

(d). On 05/26/2015 at 9:19 AM, an unsealed cable penetration was found in a corridor wall of the 4th Floor of the hospital (vicinity of room 440 and room 441).

(e). On the morning of 05/26/2015, an unsealed cable penetration and two small holes were found in a corridor wall of the 4th Floor of the hospital (vicinity of Labor/Delivery Room 5) and an unsealed cable penetration was noted in a corridor wall (vicinity of Labor/Delivery Room 3) .

(f). On 5/26/15 between 10:30 AM- 11:00 AM, unsealed conduit and wire penetrations and holes were noted in the corridor wall between the Pantry and room 301 on the 3 North unit.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.1, 19.3.6.2.1

Based on observations and interviews, the facility did not ensure that vertical electrical penetrations were properly sealed.

The findings were:

(a). On 05/22/2015 at 12:04 PM, an unprotected opening to a vertical electrical wiring chase in a 9th floor West Wing Mechanical Room (vicinity of Stair H) was found. As per concurrent interview with the facility's Director of Engineering, he acknowledged the finding.

(b). On 05/26/2015 between 2:18 and 2:20 PM, multiple holes were noted in enclosure walls of a basement level accessory stair that connects the basement to the 1st floor (Stair "E"). In addition, the self-closing device on this door did not work properly and needs to be adjusted so that the door latches in the closed position.

42CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.1.1, 8.2.5.6

Based on observations and interview, the facility did not ensure that all required smoke barrier walls were constructed to provide at least a ½-hour fire resistance rating.


Findings:


Required smoke barrier walls were not constructed to provide at least a ½-hour fire resistance rating. Reference is made to small holes and gaps in smoke barrier walls and building service equipment penetrations of smoke barrier walls that were either unsealed or not sealed with a UL Listed Through Penetration Firestop System.

Examples:


(a). On 05/22/2015 at 11:40 AM, two (2) unsealed cable penetrations were found in a 8th Floor 2-hour fire resistance rated combination fire barrier/smoke barrier wall above cross-corridor door in the vicinity of GI suite changing room and clean storage room. In addition, a duct penetration containing a motorized fire/smoke damper that penetrates the above-referenced wall was found to have been improperly sealed with fire stopping materials (e.g. firestopping caulk) that could expand when exposed to the heat of a fire and could potentially impinge upon (crush) the duct, hampering the operation of the damper. As per concurrent interview with the facility's Director of Engineering, he aknowledged the finding.



(b). On 05/22/2015 at 1:40 PM, a duct penetration containing a motorized fire/smoke damper that penetrates a 5th floor smoke barrier wall (vicinity of Stair " J " and Room 5J25) was found to have been improperly sealed with fire stopping materials (e.g. firestopping caulk) that could expand when exposed to the heat of a fire and could potentially impinge upon (crush) the duct, hampering the operation of the damper. As per concurrent interview with the facility's Director of Engineering, he aknowledged the finding.

(c). On 05/26/2015 at 8:44 AM, an unsealed cable penetration and a partially sealed conduit penetration were noted on one side of 4th floor smoke barrier wall (above cross-corridor doors near Room 410).


(d). On 05/26/2015 at 9:10 AM, a pipe was found to have been improperly incorporated in the construction of a 4th Floor 2-hour fire resistance rated combination fire barrier/smoke barrier wall inside of Exit Stair " J " .


(e). On 05/26/2015 at 9:54 AM, an unsealed cable penetration was found in a 4th floor smoke barrier wall (vicinity of entrance door to the NICU suite and an elevator lobby).


(f). On 05/26/2015 at 9:54 AM, an unsealed cable penetration was found in a 4th floor smoke barrier wall (vicinity of cross corridor door near the well-baby nursery).


42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.2.3, 8.3.3

Based on observation and interview during the survey, the facility failed to ensure that smoke barrier doors were provided with self-closing devices. This was noted for the Pre-Surgical Office door on the 3rd floor.

The findings are:

On 05/26/2015 at approximately 9:00AM, the door to the Pre-Surgical Office that was part of the smoke barrier, as indicated by the facility ' s Life Safety Drawings, was not provided with a self-closing devices.

In an interview on 05/26/2015 at approximately 9:00AM, with the facility's Director of Engineering, he acknowledged the finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.6

Based on observation and interview during the survey, the facility failed to ensure that hazardous areas shall be protected with a ¾ hour fire-rated door, protected by a sprinkler system and provided with self-closing doors. This was noted on the 3rd floor in the Operating Rooms (OR ' s) and the Basement.

The findings are:

(a). On 05/26/2015 and 05/27/2015 between 8:00am- 3:00pm, hazardous areas were not protected with a ¾ hour fire-rated door, protected by a sprinkler system, and provided with self-closing doors. Examples are:

1) OR#1 was noted converted into a storage room. The room lacked sprinkler coverage and the door was noted with a plain glass vision panel. There was no fire-rating etched on the glass or on the frame.
2) OR#9 was noted converted into a storage room. The room lacked sprinkler coverage.
3) The door to the Clean Linen Storage Room in the Basement was observed lacking a self-closing device.

In an interview on 5/26/15 at approximately 9:40 AM, the Engineering worker stated that the OR ' s were converted to storage rooms approximately 3 years ago. When the facility converted the Operating Rooms to storage rooms they failed to provide all of the fire protection features that a storage room would require (e.g., sprinkler protection, 1-hour fire resistance rated enclosure, and self-closing doors).

(b). On 05/26/2015 at 11:10 AM, a former hematology laboratory on the 2nd floor that had been converted into a storage room was found to lack required self-closing devices on the door to this room. As per concurrent interview with the facility's Director of Engineering, he acknowledged the finding. When the facility converted the laboratory to a storage room they failed to provide all of the fire protection features that a storage room would require (e.g., a self-closing door).



(c). On 05/26/2015 at 12:31 PM, the door to the Gift Shop Storage Room (vicinity of the 2nd floor main lobby) was found to lack a self-closing device. As per concurrent interview with the facility's Director of Engineering, he acknowledged the finding.


42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.2.1, 8.4

Based on observation and interview during the survey, the facility failed to ensure that exit enclosures (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour. This was noted on the 1st and 3rd floor.

The findings are:

On 05/26/2015 between 8:00 AM- 3:00 PM, the facility failed to ensure that exit enclosures and exit passageways were enclosed with construction having a fire resistance rating for at least two hours and provide protection against fire or smoke from other parts of the building. Examples include:

1) The top of wall joint of Stair I within the Intensive Care Unit (ICU) on the 3rd floor was noted sealed with joint compound and not a UL-listed fire-stopping material.
2) Partially sealed wire penetrations were noted above the door to Stair K and unsealed wire penetrations within Stair K were noted above the door to the Operating Room on the 3rd floor.
3) An insulated pipe penetration sealed with joint compound and not a UL-listed fire-stopping material was noted in Stair A in the vicinity of the Elevator Lobby on the 3rd floor.
4) Unsealed wire penetrations and holes were noted above the ceiling in the 1st floor exit passageway in the vicinity of the Radiology Nurse Office.
5) Unsealed top of the wall joint and an unsealed beam penetration were noted above the door to Stair E on the 1st floor.
6) The door to the ER (Emergency Room) office was provided with a self-closing device that holds the door in the open position and not tied into the fire alarm system. This door is part of an exit passageway on the 1st floor.
7) An unsealed conduit penetration was noted above the cross-corridor doors in the vicinity of the Physical Therapy (PT) waiting room. These doors are part of an exit passageway on the 1st floor.

In an interview on 05/26/2015 at approximately 12:40 PM, the facility's Senior Director of Engineering, he acknowledged the finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.1.3.2, 8.2.5.2, 8.2.5.4, 19.3.1.1

1. Based on observation and staff interview, the facility did not ensure that openings into exit enclosures were limited to those necessary for access to the enclosure from normally occupied spaces and corridors, and for egress from the enclosure.

Findings:

(a). On 05/22/2015 at 11:06 AM, a door from a rooftop elevator room (i.e., elevator machine room for Elevator Cabs 5-6-7)) was found to open directly into an exit enclosure (Exit Stair "D"). This machine room is not provided with sprinkler protection. As per concurrent interview with the Facility's Director of Engineering, he acknowledged the finding.

(b) On 05/22/2015 at 11:47 AM, a door from a rooftop elevator room (i.e., elevator machine room for Elevator Cabs 1-2-3-4)) was found to open directly into an exit enclosure (Exit Stair "H"). This machine room is not provided with sprinkler protection.

(c). On 05/22/2015 at 12:05 PM, a door from 9th floor machine room was found to open directly into an exit enclosure (Exit Stair "H"). This machine room is not provided with sprinkler protection.

(d). On 05/22/2015 at 1:19 PM, a door from 5th floor machine room was found to open directly into an exit enclosure (Exit Stair "K"). This machine room is not provided with sprinkler protection.

(e). On 05/27/2015 at 8:30 AM, doors from 9th floor machine room and communication equipment rooms were found to open directly into an exit enclosure (Exit Stair "G").


42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.1, 19.2.2.3, 7.2.2.1, 7.1.3.2.1 (d)

2. Based on observations and interviews during the survey, the facility failed to ensure that exit stairs were free of prohibited penetrations of the exit stair enclosure as well as being free of any impediments that have the potential to interfere with the use of the exit.

Findings were:

(a). On 05/22/2015 at 11:15 AM, electrical cables that do not serve any functions within Exit Stair " B " were found to have been improperly run from a rooftop elevator machine room into the exit stair enclosure of exit stair " B " . As per concurrent interview with the facility ' s safety director, he acknowledged the finding.


(b). On 05/22/2015 at 11:58 AM, electrical cables that serve rooftop satellite TV dishes were found to have been improperly run into the exit stair enclosure of exit stair " H " . As per concurrent interview with the facility ' s Director of Engineering, he acknowledged the finding.

(c). On 05/27/2015 at 8:30 AM, the fire door that separates a 9th floor machine room from exit stair " G " was found to have been improperly tied open. In addition, bags of tools were found to be improperly stored unattended on a 9th floor landing in exit stair " G " and a rolling work cart and ladder were improperly stored in the 8th floor landing of exit stair "G " . As per concurrent interview with the facility ' s Director of Engineering, he acknowledged the finding.

(d). On 05/27/2015 at 8:33 AM, the treads of steps between the 9th floor and the 8th floor landings in exit stair " G " were noted to be in disrepair and could be a tripping hazard to building occupants.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.2.3, 7.2.2.1, 7.1.3.2.1 (e), 7.1.3.2.3

Based on observation and interview, the facility failed to provide emergency illumination for not less than 1½ hours in the event of failure of normal lighting.

The findings are:

(a). On 05/22/2015 at 11:22 AM, emergency illumination for not less than 1½ hours in the event of failure of normal lighting was not provided for the rooftop means of egress between the exit door from the 9th floor Switchboard/Communications Suite to the door to exit stair " D " . As per concurrent interview with the facility's Director of Engineering, he acknowledged the finding.

(b) On 05/26/2015 between 12:00 PM- 1:00 PM, the facility failed to provide emergency illumination for not less than 1½ hours in the event of failure of normal lighting. Examples are:

1) Emergency lighting was not provided along the egress path from exit Stair G to the public way in the vicinity of the Employee ' s Entrance.

In an interview on 05/2720/15 at approximately 11:25 AM, the electrician stated that the wall pack lighting units in the vicinity of the Employee ' s Entrance were connected to normal power only.

2) Exit discharge lights in the vicinity of the CT trailer were noted operable by light switches. Use of switch control can leave this means of egress in darkness, hampering the use of this means of egress in an emergency.


In an interview on 05/26/2015 at approximately 12:47 PM, the Senior Director of Engineering, acknowledged the finding.


(c). On 05/26/2015 at 1:28 PM, emergency lighting in the exit access corridor by the rear exit from the 2nd floor Breast Health unit were operable by light switches. Use of switch control can leave this means of egress in darkness, hampering the use of this means of egress in an emergency.


42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.9.2.1, 7.9.2.2

Based on observation and interview during the survey, the facility failed to ensure the protection of all persons in the event of a fire and for their evacuation to areas of refuge. Reference is made to the smoke barrier in the vicinity of the 3rd floor Pre-Surgical Office that is arranged so that the body of the Pre-Surgical Office is in one smoke compartment but the only exit from this room opens into the adjacent smoke compartment.

The findings are:

On 05/26/2015 at approximately 9:00 AM, the door to the Pre-Surgical Office was noted to be part of the smoke barrier, as indicated by the facility' s Life Safety Drawings. The body of the office was in one smoke compartment but the only exit from the room opens into the adjacent smoke compartment. This arrangement would require the evacuation of this room in the event of a fire in either smoke compartment.

In an interview on 05/27/2015 at approximately 9:55 AM, the Director of Environmental Health and Safety acknowledged this finding and stated that the current fire plan does not address this special circumstance.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.7.1.1, 19.7.2.2

1. Based on observation and interview during the survey, the facility failed to ensure that required automatic sprinkler systems were continuously maintained in reliable operating condition. This was noted on the 3rd & 1st floors and the Basement.

The findings are:

(a). On 05/22/2015 at 11:14 AM, a sprinkler in the 9th floor landing of stair " B " was noted to have a foreign material (e.g., paint) on it.

On 05/26/2015 to 05/27/2015 between 8:00 AM- 3:00 PM, the automatic sprinkler system was noted to not being continuously maintained in reliable operating condition. Examples include but are not limited to:

1) External loads were noted hanging from sprinkler pipes in the following areas:
a. Multiple ceiling grids and light fixtures on the 3 North unit.
b. Wiring connected to sprinkler piping in the Basement East Main Storage Room
c. Wiring connected to sprinkler piping in the 2nd floor main lobby of the hospital building

2) Painted or loaded sprinkler heads or escutcheons in the following areas:
a. Staff bathroom within the corridor to the 3 North unit- spackle on a pendent sprinkler head.
b. 1st floor main lobby- two painted concealed sprinkler escutcheon cover plates.
c. Basement- painted upright sprinkler heads in the Sump Pump Room, Housekeeping Storage Room and Laundry Room.
d. Basement painted upright sprinkler in the East main Storage Room.
e. Two (2) concealed sprinkler escutcheon cover plates in the suspended ceiling of 2nd floor main lobby of the hospital building had been painted.


3). Sprinkler support brackets not maintained in the following areas:
(a) Three (3) sprinkler piping support hangers that were in disrepair in a basement housekeeping storage room.
(b). Bailing wire was improperly used as a sprinkler piping support hanger above the suspended ceiling in the 2nd floor main lobby of the hospital building.

During an interview on 5/27/15 at approximately 8:08 AM, the Director of Engineering acknowledged this finding

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.7.5, 1998 NFPA 25: 2-2.1.1



2. Based on observation and interview during the survey, the facility failed to ensure that each sprinkler system control valve was identified and each have a sign indicating the system or portion of the system it controls. This was noted on the 2nd floor and the Basement.

The findings are:

On 05/26/2015 between 8:00 AM- 3:00 PM, control valves for the sprinkler system were noted to be lacking signs identifying the system or portion of the system it controls.
Examples include but are not limited to:

1) Above the drop ceiling within Stair A at the 2nd floor landing.
2) Basement corridor in the vicinity of Stair A.
3) Basement corridor outside of the Fire Pump Room.
4) Basement Fire Pump Room.
5) Basement corridor outside of the Linen Chute Room.
6) Basement corridor in the Center Elevator Lobby.

In an interview on 05/26/2015 at approximately 1:43 PM, the Senior Director of Engineering, acknowledged the findings.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.7.5, 1998 NFPA 25: 9-3.2

1. Based on observations and staff interviews, the facility failed to ensure that portable fire extinguishers were installed in accordance with the requirements found in NFPA 10, Standard for Portable Fire Extinguishers.

The findings were:

(a). On 05/22/2015 at 2:20 PM, a fire extinguisher that was stored in a recessed cabinet in a wall of the 5th floor North Diabetes Educational Conference Center was noted to lack a required identification sign. When the physical location of a portable fire extinguisher is not readily visible, another form of location identification (e.g., signage) is required.

(b). On 05/22/2015 at 2:28 PM, a fire extinguisher that was stored in a recessed cabinet in a wall of the 5th floor (near entrance to breezeway by the 5 Joyce wing) was noted to lack a required identification sign. When the physical location of a portable fire extinguisher is not readily visible, another form of location identification (e.g., signage) is required.

As per concurrent interviews with the facility ' s Director of Safety, acknowledged this finding.


42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.6, 9.7.4.1, NFPA 10-1998 Standard for Portable Fire Extinguishers: 1-6.10, 1-6.3, 1-6.6

2. Based on observations and staff interview during the survey, the facility failed to ensure that portable fire extinguishers were maintained and tested in accordance with the requirements found in NFPA 10, Standard for Portable Fire Extinguishers.

The finding was:

On 05/26/2015 at 12:47 PM, a portable fire extinguisher located in a 2nd floor Central Sterile area cart washer equipment room was found to have last been hydrostatically tested in January, 1999, the pressure gauge indicated that the fire extinguisher was overcharged, and there was no monthly inspection tag on the fire extinguisher. As per concurrent interview with the facility ' s Director of Engineering, he acknowledged the finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.6, 9.7.4.1, NFPA 10-1998 Standard for Portable Fire Extinguishers: 4-3.1, 4-4.1, 4-4.4, 5-1. Table 5-2

Based on observations and staff interview during the survey, the facility failed to ensure that required placards identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system were conspicuously placed near each portable fire extinguisher in Cooking Areas.

The findings are:

On 5/26/15 at approximately 11:05 AM, the facility was found lacking the required placard (sign) identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system near the portable " K " type fire extinguishers in the 3rd floor Cafeteria. The required placard shall state " WARNING: In case of appliance fire use this extinguisher after fixed suppression system has been used " .

In an interview on 5/26/15 at approximately 11:05 AM, the Senior Director of Engineering acknowledged this finding.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96-1998 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 7-2.1.1

1. Based on observations and staff interviews during the survey, the facility did not ensure that electrical fixtures in oxygen storage locations were mounted at least 60- inches above the finished floor as a precaution against their physical damage.

The findings were:

(a). On 05/22/2015 at 1:43 PM, an electrical light switch in a compressed medical gas (e.g., oxygen) cylinder storage room on the 5th floor of the hospital (vicinity the nurse ' s station in the 5J unit) was installed at a height of 50-inches above the floor.

(b). On 05/26/2015 at 9:28 AM, an electrical light switch in a compressed medical gas (e.g., oxygen) cylinder storage room on the 4th floor of the hospital was installed at a height of 50-inches above the floor.


(c). On 05/26/2015 at 11:20 AM, an electrical light switch which had a damaged plastic cover plate in the 2nd floor pathology lab (located next to carbon dioxide tanks/manifold system) was installed at a height of only 50-inches above the finish floor.

(d). On 05/26/2015 at 11:25 AM, an electrical light switch in a compressed medical gas (e.g., nitrogen and nitrous oxide) cylinder storage/manifold room on the 2nd floor of the hospital was installed at a height of 47-inches above the floor.


As per concurrent interviews with the facility ' s Director of Engineering, he acknowledged these findings.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 4-3.1.1.2 (a) (4), (c)


2. Based on observations and staff interview, the facility did not ensure that vehicles did not park any closer than 10-feet from exposed piping at the bulk oxygen storage location or that NO PARKING signs were properly installed or maintained.

The finding was:

On 05/26/2015 at 1:37 PM, a SUV (NY license # CUH-4814) was found to have been parked only 80-inches from exposed piping at the hospital ' s bulk oxygen storage location (vicinity of the north side of the enclosure). Parked vehicles are required to be at least 10-feet (120-inches) from any exposed piping. In addition, there was no "NO PARKING" sign posted on the north side of the bulk oxygen storage location and the writing on the "NO PARKING" sign on the south side of the enclosure was so faded that it was almost illegible. As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.2.4, NFPA 99-1999, Standard for Health Care Facilities: 4-3.1.1.2 (b) (1), NFPA 50-1996, Standard for Bulk Oxygen Systems at Consumer Sites: 2-2.12

Based on observation and interview during the survey, the facility failed to ensure that penetrations of smoke barriers by ducts are protected in accordance with 8.3.5 in that smoke dampers were noted lacking within the duct above the smoke barrier doors between the Intensive Care Unit (ICU) and Recovery on the 3rd floor.

The findings are:

On 5/26/15 at approximately 8:51 AM, a duct penetration above the smoke barrier doors between ICU and Recovery on the 3rd floor was noted lacking a smoke damper.

In an interview on 5/26/15 at approximately 8:51 AM, the Senior Director of Engineering acknowledged this finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3.5.1

1. Based on observation and interview during the survey, the facility did not ensure that the safety of the building containing a healthcare occupancy was not compromised by the placement of non-fire resistance rated combustible structures less than 10-feet from unprotected windows.

Finding:

On 05/22/2015 at 10:50 AM, a Type (V) (000) construction type wooden structure (a connecting corridor that attaches the main hospital to a trailer containing a CT scanner (the " CT Scanner" Building) was found to have been installed approximately 8-feet from two unprotected windows in the main hospital building. A 90-minute fire door and 2-hour fire resistance rated exterior wall separate the main hospital building from the wooden accessory structure. The connecting structure was found to have: a hardwired fire alarm system, a hardwired emergency lighting system, hardwired exit directional signage, portable fire extinguishers, and that dimensional lumber used in the construction had been treated with INSL-X brand intumescent fire retardant paint, and that Pyroguard brand fire retardant plywood was used for wall and roof sheathing. The only fire safety concern is the window openings.

As per concurrent interviews with Facility's Director of Engineering and Safety Officer, the facility had not obtained required New York State Department of Health approval of this project at the time of the inspection.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.1.6.2, NFPA 80, Standard for Fire Doors and Fire Windows, NFPA 80A, Recommended Practice for Protection of Buildings from Exterior Fire Exposures


2. Based on observations and interviews, the facility failed to ensure that buildings that containing atriums were fully sprinklered and the facility failed to ensure that other requirements for buildings containing atriums were met.

Findings:

Observations on the afternoon of 05/27/2015 revealed that the building had a two (2) level Atrium between the 2nd and 3rd floor and that the Atrium was not constructed in accordance with NFPA 101-2000: 8.2.5.6.

(a) The entire building is not provided with sprinkler protection. For example, portions of the 2nd floor (e.g., the breast health unit) and 3rd floor (e.g., the ambulatory surgery unit recovery area) that are open to the atrium, as well of portions of the atrium itself lack sprinkler protection.

Sprinklers were found to be missing in 4th floor maternity unit electrical closet (it was also noted that this closet was not enclosed by at least 2-hour fire barriers, so it would not meet the listed exception for not having a sprinkler), and air handling equipment room, 2nd floor administrative suite, 7th floor on-call rooms (e.g., Room 705W), an rooftop machine rooms. Some of the exit stairs lacked sprinkler protection, and the 2nd floor pharmacy " Forma " freezer storage alcove lacked sprinkler protection.

(b). On the afternoon of 05/26/2015, it was noted that the fire alarm panel in the 2nd floor elevator lobby of the atrium identified that this area was provided with a "smoke purge" capability.

As per interview with the facility ' s Director of Engineering on 05/26/2015 at approximately 1:20 PM, he acknowledged this finding and said that he was not sure if the smoke purge system was operational.

On the morning of 05/27/2015, facility staff were unable to provide any evidence that the smoke purge system was being maintained and tested nor could they provide a written policy and procedure for the maintenance and testing of this system. It should be noted that the atrium smoke control system must be able to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 ft (1.85 m) above the highest floor level of exit access open to the atrium for a period equal to 1.5 times the calculated egress time or 20 minutes, whichever is greater. The engineered smoke control system must be is independently activated by each of the following:
a. The required automatic sprinkler system
b. Manual controls that are readily accessible to the fire department


42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 8.2.5.6




3. Based on observations and staff interview during the recertification survey, the facility failed to ensure that the integrity of fire barriers were maintained.

The findings were:

(a). On 05/22/2015 at 11:44 AM, two unsealed cable penetrations were found above the cross-corridor 2-hour fire resistance rated fire barrier door between the 9th floor 1980 ' s and 1960 ' s wings. As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding.

(b). On 05/22/2015 at 12:20 PM, an unsealed cable penetration was found above the cross-corridor 2-hour fire resistance rated fire barrier door between the 7th floor 1980 ' s and 1960 ' s wings. As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding.

(c). On 05/26/2015 at 9:30 AM, an unsealed cable penetration was found above the cross-corridor 2-hour fire resistance rated fire barrier door vicinity of the entrance to the 4th floor maternity wing (vicinity of the visitor toilet room).

(d). on 05/26/2015 at 1:58 PM in the basement Red Bag storage room, the actuator arm on a motorized smoke damper in the fire barrier in this room was noted to be in disrepair and that the damper would not be able to function.

(e). On 05/26/2015 at 2:44 PM, a plumbing penetration of a 2-hour fire resistance rated barrier wall that separates the basement of the hospital from the adjacent nursing home building was found to have been improperly sealed with an unapproved, non-fire resistance rated material (e.g., polyurethane expansion foam) on one side of the fire barrier wall.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.1.1.4.1, 8.2


4. Based on observation and staff interview during the survey, the Facility failed to ensure that the arrangements of all means of egress in the hospital were in accordance with NFPA 101-2000: 19.2.5.

The finding was:

On morning of 05/26/2015, it was noted that a designated means of exit access from a 4th floor maternity unit elevator lobby was directed through intervening rooms or spaces (e.g., Neonatal Intensive Care Unit suite). Exit access corridors are required to provide access to exits without passing through any intervening rooms or spaces other than corridors or lobbies. As per interview with the Facility's Director of Engineering on 05/26/2015 at 9:55 AM, he acknowledged this finding and said that he would inform the hospital ' s administration of this issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.5.9, 7.4, 7.5

5. Based on observations and staff interview during the survey, the facility failed to ensure that doors in a means of egress were operable with not more than one releasing operation.

The finding was:

On 05/26/2015 at 12:34 PM., to was noted that the exit door from the 2nd floor gift shop was provided with two different door latching mechanisms on the egress side of the door when only one is permitted. As per concurrent interview with the facility ' s Director of Environmental health and safety, he acknowledged this finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.2.1.5.4

6. Based on record review and staff interview, the facility did not ensure that Ambulatory health care facilities were separated from other tenants and occupancies by walls having not less than a 1-hour fire resistance rating.

The finding was:

On 05/26/2015 at 1:35 PM, review of life safety plan for the 2nd floor of the hospital (drawing number MHS-NRH-TW-02 dated 02-11-2015) indicated that an existing tenant (a chronic dialysis clinic that is an Existing Ambulatory Healthcare Occupancy) was not separated by at least 1-hour fire barriers from adjacent areas of the hospital (e.g., vicinity of the women ' s breast health clinic. As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding and could not provide evidence that the required separation existed prior to the exit.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 21.3.7.1

1. Based on observations and record (i.e., pane board schedule) reviews, and staff interviews during the survey, the hospital was not provided with a Type 1 Essential Electrical System that was divided into separate critical branch, life safety branch, and equipment systems in accordance with NFPA 99. In addition, the facility failed to ensure that normal service wiring was separated from emergency service wiring. These deficiencies were noted in existing areas of this hospital.

The findings were:


(a). On 05/26/2015 at 8:46 AM, review of the emergency power panel directory for panel " EA " in the 4th floor of the hospital was found to serve both Emergency System-Life Safety Branch loads (e.g., exit signs, medical gas alarm, hall lights) and Emergency System-Critical Branch loads (e.g. nurse call system, Pyxis machine and hall receptacles, T.V. power supply).

As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding and said that he would notify hospital administration concerning this condition.


(b). On the morning of 05/26/2015, review of the emergency power panel directory for panel " EL-4 " in the 4th floor of the hospital was found to serve both Emergency System-Life Safety Branch loads (e.g., exit lights, exit stair lighting) and Emergency System-Critical Branch loads (e.g. hall receptacles, nursery task lighting, infant abduction system).

(c). On the morning of 05/26/2015, review of the emergency power panel directory for panel " S-E " in the 4th floor of the hospital was found to serve both Emergency System-Life Safety Branch loads (e.g., exit lights in nursery area, medical gas alarm) and Emergency System-Critical Branch loads (e.g. Neonatal Intensive Care Unit (NICU) and other patient room receptacles).

(d) On the morning of 05/26/2015, review of the emergency power panel directory for panel " 3-N " in the 3rd floor of the hospital was found to serve both Emergency System-Life Safety Branch loads (e.g., medical gas alarm, corridor lights) and Emergency System-Critical Branch loads (e.g. treatment room task lighting, treatment room receptacles, nurse call system).

(e). On the morning of 05/26/2015, review of the emergency power panel directory for panel " S-H " in the 1st floor of the hospital was found to serve both Emergency System-Life Safety Branch loads (e.g., exit lights) and Emergency System-Critical Branch loads (e.g. corridor and patient room receptacles, nurse call system).

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9

1. Based on observations and staff interview during the survey, the facility failed to ensure that all panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors in accordance with the requirements of NFPA 70, National Electrical Code.
The findings include, but are not limited to, the following:

(a). On 05/22/2015 at 11:08 AM, it was observed in the rooftop penthouse next to the elevator machine room by stair " B " that an electrical panel (panel " 2093 " ) lacked any panel direct function identification directory.

As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding.

(b). On 05/22/2015 at 2:05 PM, it was observed in the 5th floor Joyce wing that an electrical panel (panel " 5 DEN " ) lacked any panel direct function identification directory.

(c). On 05/26/2015 at 11:20 AM, a 2nd floor emergency power panel located in the corridor near the entrance to the main laboratory suite was observed to lack any panel direct function identification directory.

(d). On 05/26/2015 at 1:05 PM, a 2nd floor emergency power panel (e.g., labeled " critical branch " located in the corridor near the entrance to chronic dialysis clinic was noted to lack any panel direct function identification directory.



42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13

2. Based on observations and staff interview during the survey, the facility failed to ensure that electrical wiring was installed in a neat and workman like manner or maintained in good repair, and that unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment were provided in accordance with the requirements of NFPA 70, National Electrical Code.
Findings include, but not limited to, the following:

(a). On 05/22/2015 at 1:53 PM, an approximately 4-inch by 4-inch electrical junction box (located above the suspended ceiling in the 5th floor breezeway between the Joyce wing and the East wing) lacked a cover plate on one side of the box.

(b). On 05/26/2015 at 11:24 AM, an approximately 4-inch by 4-inch electrical junction box was in the compressed medical gas (e.g., nitrogen and nitrous oxide) cylinder storage/manifold room on the 2nd floor of the hospital lacked a cover plate on one side of the box.

(c). On 05/26/2015 at 2:11 PM, several open (e.g., uncovered) junction boxes and electrical raceways were noted in a basement housekeeping storage room.

(d). On the morning of 05/27/2015, in four (4) separate instances, electrical wiring (e.g., BX cable) above the suspended ceiling in the 2nd floor main lobby of the hospital were improperly spliced together and were not properly enclosed in an approved electrical junction box.

As per concurrent interviews with the facility ' s Director of Engineering, he acknowledged this finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12

3. Based on observations and staff interviews, the facility failed to ensure that flexible cords and cables are not used as a substitute for the fixed wiring of a structure.
The finding was:
On 05/26/2015 at 11:13 AM in the microbiology laboratory unit on the 2nd floor of the hospital, an extension cord found to be improperly used to supply power to a microscope. As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding.
NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3, 400-8

4. Based on observation, record reviews, and staff interviews, the facility failed to ensure that electrical equipment was tested in accordance with manufacturer's instructions and their listing.

The finding was:

On 05/26/2015 at 1:26 PM, a duplex ground fault circuit interrupter (GFCI) electrical receptacle in the 2nd floor women ' s breast health clinic toilet room (near the elevator lobby) was found to be labeled by the manufacturer " TEST MONTHLY " . As per concurrent interview with the facility ' s Director of Engineering, he acknowledged this finding and said that he was not aware that he was required to test these receptacles on a monthly basis and had no testing records for these devices.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3 (b)