HospitalInspections.org

Based on observations during the Life Safety Code survey, it was noted that structural components of the facility were not properly protected from fire. Issues include structural steel /steel beams of the building and the beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type I (443).

The findings are:

During the survey from 04/15/13 to 04/22/13 between 11:00 AM to 4:00 PM, it was observed that the ceiling assembly located throughout the building was comprised of lay-in ceiling tiles. Observations made above the suspended ceilings, in mechanical areas and other areas where the structural beam was visible from the floor level, it was revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above were not completely protected with a fire resistive material.

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

i. Areas of the I-beam observed above the ceiling near the double fire/smoke door on 3rd floor Milstein Building were noted missing fire spray at places.

ii. The beams in the mechanical room on B3 level of Milstein building ( that houses the ATS switches and generator) was noted devoid of fire spray/retardant in multiple places.

iii. Some areas of the I-beam on 6th floor Hudson of Milstein Building were noted missing fire spray/retardant material above the smoke/fire double door near 6HS-202.

iv. Some areas of the I-beam on 8th floor Garden of Milstein Building were noted missing fire spray/retardant material in the electrical closet near the Rehab unit.

Findings were verified with Director of Environmental and Health Safety, Director of Facilities and Field Director of Regulatory/Fire Safety.

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

Based on observation, it was determined that the facility failed to ensure that all doors in the smoke barrier were arranged as such that they will automatically close by activation of Fire Alarm/Sprinkler system and there is no impediment to the closure..

Findings include:

On 04/16/13 at 3:00 PM during the survey of Infusion Center 14th floor (Herbert Irving Building) it was noted that the one leaf of the fire/smoke double door was held open by a wooden door wedge. This situation prevents the door to automatically close completely in case of fire situation/alarm.

The issue of door wedges/stoppers used to hold open corridor doors and other kind of doors protecting the room/area/barrier were noted sporadically in various other areas of the facility during the full tour from 04/15/13 to 04/23/13.

Findings were observed and verified with Director of Environmental and Health safety, Filed Director for Regulatory compliance/Fire Safety and other staff escorting the surveyor during survey.

Based on observation and staff interview, the facility failed to ensure that the access to exits are marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4

Findings included but were not limited to:

On 04/23/13 at 11:30 AM, during the tour of the Main Supplies Storage Management/receiving area in the Service Building, it was noted that in one of the areas where bulk supplies items were stored in shelves of almost 6 to 7 feet, the room/area did not have exit signs in all areas to direct the staff to the exit doors in the event of fire or smoke conditions.

Furthermore, one of the EXIT lights was noted with a fuse bulb by one of the exit door.

These findings were identified in the presence of Director of Environmental and Health Safety, Filed Director Regulatory Compliance/Fire Safety and other staff such as the Supervisor of the area.

Based on observations, the facility failed to ensure that smoke barriers were constructed and maintained to resist the passage of smoke.
Findings include:

1- The electric closet 9GN-420 was found to have multiple penetrations that were not sealed by the proper fire stops and part of the wall sheet rock was missing.
2- - The smoke wall (partition) of telephone closet room# 9GN-447A was not extended to the slab above, leaving a gap of penetration that was not sealed by the proper fire stop.
3- The 30 minutes fire and smoke rated walls of the telecommunication room were observed to have penetrations that were not sealed by the proper fire stops.






26934

Based on observations and testing, the facility failed to ensure that the fire/smoke barrier doors dividing the facility into smoke/fire compartments are maintained to provide tight smoke resistance.

Findings include:

On 04/15/13 PM, during the tour of the OR suite on 4th and 3rd floor of Milstein Building, it was noted that the fire/smoke barrier doors on both floors were of the swinging type and held open with electromagnetic holding devices. When the door was manually released and an attempt was made to close it, the panels of the door did not close completely. This situation compromised the smoke resistant status of the door and in case of fire/smoke will not provide a smoke-tight partition as was intended by the building construction/arrangement.

Furthermore, a similar finding was note on 04/19/13 at 2:30 PM, for the double door of the Emergency Department ( by the ambulance entrance).

Findings were observed and verified with Director of Environmental and Health Safety, Field Director for Regulatory compliance/Fire Safety, and other staff escorting the surveyor during survey.

Based on observation, facility did not ensure that the buildings having staircase serving 5 or more stories ( such as Herbert Irving) had an identification sign complying with the elements as stated in NFPA 101 section 7.2.2.5.4.

Findings Include:

During the tour of the 13th Floor Herbert Irving pavilion on 04/16/13 at 3:00 PM, when staircase B was inspected it was noted that the sign identifying the staircase did not comply with the provision of NFPA 101 7.2.2.5.4.

Findings were verified with Director of Facilities, Director of Environmental and Heath Safety and other staff escorting the surveyor at the time of observation.

Note: NFPA 101 2000 7.2.2.5.4* Stair Identification Signs.
Stairs serving five or more stories shall be provided with signage within the enclosure at each floor landing. The signage shall indicate the story, the terminus of the top and bottom of the stair enclosure, and the identification of the stair enclosure. The signage also shall state the story of, and the direction to, exit discharge. The signage shall be inside the enclosure located approximately 5 ft (1.5 m) above the floor landing in a position that is readily visible when the door is in the open or closed position.

A. Based on document review and staff interview, it was determined that the hospital did not ensure that the sprinkler system maintenance/tests were done as per NFPA 13 and NFPA 25 to ensure that the system is in operating and reliable condition as per the codes.

Findings include:

On 04/18/13 from 11:00 AM to 4:00PM, during the document review of different buildings and campuses of the facility, the following was noted regarding the test and maintenance of the sprinkler system

i. A three year full Dry pipe valve flow test for the sprinkler systems was not provided for Milstein or any of the campuses/building of the facility. Only partial annual trip test reports were provided. A full dry pipe trip test of sprinkler system is required by NFPA 25 1998 9-1.

ii. During the review for the sprinkler test reports it was noted that there was no documentation or report available for the sprinkler system of Milstein or any other campuses/building to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves were conducted. It could also be not verified if the gauges were recalibrated or replaced in the past five years for the sprinkler systems of the different buildings/campuses.

Note: As per NFPA, there are two activities that are related to obstructions in Chapter 13 that require attention. The first is an investigation that is actually more of an "inspection" as described in Section 13.2.1 that must be conducted every five years. While the sprinkler system is shut down for the purpose of internal valve inspections (See Table 12.1), the flushing connection at the end of one cross main and a single sprinkler at the end of one branch line must be removed and the inside of the piping is then "inspected" for the presence of organic and inorganic material. In Section 13.2.2 a more comprehensive obstruction "investigation" must be conducted when any of the 14 conditions listed in that section are present. This more comprehensive obstruction "investigation" is conducted by internally examining the following four points in a system: system valve, riser, crossmain and, branchline.

iii. The facility did not have for all campuses/buildings the comparison of the static and residual pressure for the main drain test report. Furthermore, for main drain test report having low pressure (such as the report for Allen Building dated 02/20/13) there was no verification if it was compared against the hydraulic name plate and was acceptable/normal.

Findings were observed and verified with respective Director of Facilities/Supervisors of the campuses/buildings and Director of Corporate Management Services..

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


Findings include:

During the tour of the 7th floor of Eye Institute on 04/22/13 between 11:45AM, it was observed that the exposed sprinkler pipes in various areas of the floor exhibited accumulation of lint, dust and dirt

Note: Section 2-2.1.1* of NFPA 25 states that, "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

All findings were observed and verified with Director of Environmental and Health Safety, Director of Facilities and other staff escorting the surveyor during survey.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such 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:

During survey of facility from 04/15/13 to 04/23/13 from 10:30AM to 3:45PM, it was noted that in various floors of the different buildings of the facility, the fire extinguishers were installed ( such as the one in Emergency Department, one to ICU-Medicine A) on the wall or in the recess cabinet is such a way that its topmost portion was greater than the required 5 ft. (60 inches).

All findings for high extinguishers were observed and verified with Director of Environmental and Health Safety, Director of Facilities, and Field Director Regulatory Compliance/Fire Safety.

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

The findings were:

During the tour of different parts of the facility from 04/15/13 to 04/23/13 between 10:45 AM to 4:00PM, impediments in the path and means of egress were noted.

i. On 04/15/13 at 12:00 PM , during a tour of the OR suite (4th floor Milstein) it was noted that the alcove/corridor in the rear exit from the suite ( outside the perfusion room) was blocked by a big garbage receptacle, turnover cart and housekeeping cart. These items were placed as such that in case of emergency the stretcher for the patients cannot be freely rolled out the exit as they will provide hindrance and were blocking the path of egress.


ii. On 04/16/13 at 12:30 PM, during the tour of Medicine ICU-A(4th floor Milstein Hospital) it was noted that the corridors/path of egress of the suite was cluttered with different equipments and chairs. This arrangement creates an impediment in the path of egress/means of egress to reach the exit corridor in case of fire.

iii. On 04/16/13 at 3:00 PM, during the tour of the Endoscopy suite in the Herbert Irving building, it was noted that there were stretchers outside the Endoscopy rooms in the exit corridors. Thus this arrangement was obstructing the corridor for easy access during fire emergency.
All findings were observed and verified with Director of Environmental and Health Safety, Director of Facilities, and other staff escorting the surveyor during survey.

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

The findings include:

During the survey from 04/15/13 10 04/23/13 between 1:00 AM to 4:00 PM, it was observed that the facility had provided decorative artificial plants about 4.0-5.0 feet tall in the lobby of the Milstein Building.

Furthermore on 04 /17/13 at 12:45PM, during the tour of the Rehabilitation Unit (8th floor-Milstein Building), it was noted that the Occupational Therapy room had artificial flowers and trees. An interview with Filed Director Regulatory Compliance/Fire Safety at the time of observations revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. He stated that he did not think that those plants were rendered flame retardant by any chemical treatment and stated that he will try to look for the specifications.

Therefore, no flame retardant verification was provided for the tall plants in the main lobby of Milstein or the plants of Occupational Therapy.

Based on observation in the different areas of the facility, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls and penetrations made through floors were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6

Findings include:

During the tour of the facility from 04/15/13 to 04/23/13 between 11:00 AM to 4:00 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected for the integrity of smoke barriers. The rated walls of different areas were also inspected for integrity. The penetrations made through one floor to the other in mechanical/electrical/it closets were also observed.

It was noted that the barriers and floors were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes. These penetrations were not completely sealed all around with an approved fire retardant material to prevent passage of smoke from one compartment to the other.

Examples, including but not limited to:


a. On 04/15/13 at 12:45PM, during the tour of the 3rd and 4th floor OR suite ( Milstein building), it was noted that above ceiling of the main fire/smoke barrier rated wall there were unsealed penetrations made by wires and cables

b. On 04/16/13 at 2:45 PM, during the tour of the Infusion Center (Herbert Irving) , it was noted that the electrical closet had miscellaneous penetrations of the fire rated wall with improperly sealed wires and pipes/conduits.

d. On 04/17/13 at 1:00 PM, penetrations were noted above the drop ceiling by smoke door ( near 6HS 202). The rated wall of the shaft had a hole. Penetrations were noted by double door of 6 HN 130.

c. On 04/19/13 at 2:45 PM during the tour of the Adult Emergency Department, the IT closet/rated shaft by VC #138 had penetrations to the corridor wall.

d. On 04/22/13 at 12:45PM, many penetrations were noted going through the floor to the electrical/IT room above and the penetration was not sealed with any fire retardant material.

e. On 04/22/13 at 2:00PM, various penetrations made by wires, cables and some holes were noted in the fire/smoke barrier on the 3rd floor Heart Center ( connecting with Milstein) by bays 9 & 10.

Various other floor to floor or floor to corridor penetrations were noted in the electrical/IT closets of the various buildings of the facility. All observations and findings of the various sites of issues were verified with Director of Facilities, Director of Environmental and Health Safety , Field Director Regulatory Compliance/Fire Safety, and other engineering staff escorting the surveyor.

Note: Section 8.3.6.1 of NFPA 101 states that:

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

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

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

b. It shall be protected by an approved device that is designed for the specific purpose.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13 1999 [Standard for the Installation of Sprinkler Systems], to provide complete coverage in the fully sprinklered smoke compartment of CHONY Central-3rd floor.

Findings include:

On 04/24/13 at 12:15 PM during the tour of the Microbiology Laboratory on 3rd floor CHONY Central, it was noted that the laboratory is a part of a smoke compartment (as per the floor plan) and as per the staff the compartment is fully sprinklered.

A walk-in-cooler/refrigerator was noted not having any sprinkler head, thus the compartment is not fully sprinklered.

Findings were observed and verified with Director of Corporate Management Services and Director of Environmental and Health Services.

Based on staff interview, it was determined that the facility did not ensure that the elevators in the Milstein building were wired as per NFPA 99 3.4.2.2.2 to the life safety branch of Type I EES system

Findings include:

On 04/17/13 at 3:30 PM, during the tour of the mechanical room housing the ATS switches for the emergency generators, the staff/electrician was requested to provide information regarding what items were supplied by the life safety branch and critical branch of the emergency generator (a conclusion could not be made by looking at the labels/directory of the ATS panels).

On 04/18/13 at 1:00 PM, the staff/electrician for the Milstein Building stated/confirmed that the lighting and cab of the elevators were not hooked up to the life safety branch of the Type 1 EES.

Note: As per the code NFPA 99 3.4.2.2.2 (b)(6), Elevator cab lighting, control, communication, and signal systems should be on life safety branch and not on the equipment branch. For the equipment branch of Type I EES, the code is:

Section 3.4.2.2.3(e) "Equipment for Delayed-Automatic or Manual Connection. The following equipment shall be arranged for either delayed-automatic or manual connection to the alternate power source [also see A-3-4.2.2.3(d)]:
(2)'Elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power [For elevator cab lighting, control, and signal system requirements, see 3-4.2.2.2(b)(6).]'.

Similar finding was brought to the attention of the surveyor for Allen Hospital/Building.
Findings were verified with respective Director of Facilities/Supervisors of the campuses/buildings and Director of Corporate Management Services.

Based on observations during the Life Safety Code survey, it was noted that structural components of the facility were not properly protected from fire. Issues include structural steel /steel beams of the building and the beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type I (443).

The findings are:

During the survey from 04/15/13 to 04/22/13 between 11:00 AM to 4:00 PM, it was observed that the ceiling assembly located throughout the building was comprised of lay-in ceiling tiles. Observations made above the suspended ceilings, in mechanical areas and other areas where the structural beam was visible from the floor level, it was revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above were not completely protected with a fire resistive material.

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

i. Areas of the I-beam observed above the ceiling near the double fire/smoke door on 3rd floor Milstein Building were noted missing fire spray at places.

ii. The beams in the mechanical room on B3 level of Milstein building ( that houses the ATS switches and generator) was noted devoid of fire spray/retardant in multiple places.

iii. Some areas of the I-beam on 6th floor Hudson of Milstein Building were noted missing fire spray/retardant material above the smoke/fire double door near 6HS-202.

iv. Some areas of the I-beam on 8th floor Garden of Milstein Building were noted missing fire spray/retardant material in the electrical closet near the Rehab unit.

Findings were verified with Director of Environmental and Health Safety, Director of Facilities and Field Director of Regulatory/Fire Safety.

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

Based on observation, it was determined that the facility failed to ensure that all doors in the smoke barrier were arranged as such that they will automatically close by activation of Fire Alarm/Sprinkler system and there is no impediment to the closure..

Findings include:

On 04/16/13 at 3:00 PM during the survey of Infusion Center 14th floor (Herbert Irving Building) it was noted that the one leaf of the fire/smoke double door was held open by a wooden door wedge. This situation prevents the door to automatically close completely in case of fire situation/alarm.

The issue of door wedges/stoppers used to hold open corridor doors and other kind of doors protecting the room/area/barrier were noted sporadically in various other areas of the facility during the full tour from 04/15/13 to 04/23/13.

Findings were observed and verified with Director of Environmental and Health safety, Filed Director for Regulatory compliance/Fire Safety and other staff escorting the surveyor during survey.

Based on observation and staff interview, the facility failed to ensure that the access to exits are marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4

Findings included but were not limited to:

On 04/23/13 at 11:30 AM, during the tour of the Main Supplies Storage Management/receiving area in the Service Building, it was noted that in one of the areas where bulk supplies items were stored in shelves of almost 6 to 7 feet, the room/area did not have exit signs in all areas to direct the staff to the exit doors in the event of fire or smoke conditions.

Furthermore, one of the EXIT lights was noted with a fuse bulb by one of the exit door.

These findings were identified in the presence of Director of Environmental and Health Safety, Filed Director Regulatory Compliance/Fire Safety and other staff such as the Supervisor of the area.

Based on observations, the facility failed to ensure that smoke barriers were constructed and maintained to resist the passage of smoke.
Findings include:

1- The electric closet 9GN-420 was found to have multiple penetrations that were not sealed by the proper fire stops and part of the wall sheet rock was missing.
2- - The smoke wall (partition) of telephone closet room# 9GN-447A was not extended to the slab above, leaving a gap of penetration that was not sealed by the proper fire stop.
3- The 30 minutes fire and smoke rated walls of the telecommunication room were observed to have penetrations that were not sealed by the proper fire stops.






26934

Based on observations and testing, the facility failed to ensure that the fire/smoke barrier doors dividing the facility into smoke/fire compartments are maintained to provide tight smoke resistance.

Findings include:

On 04/15/13 PM, during the tour of the OR suite on 4th and 3rd floor of Milstein Building, it was noted that the fire/smoke barrier doors on both floors were of the swinging type and held open with electromagnetic holding devices. When the door was manually released and an attempt was made to close it, the panels of the door did not close completely. This situation compromised the smoke resistant status of the door and in case of fire/smoke will not provide a smoke-tight partition as was intended by the building construction/arrangement.

Furthermore, a similar finding was note on 04/19/13 at 2:30 PM, for the double door of the Emergency Department ( by the ambulance entrance).

Findings were observed and verified with Director of Environmental and Health Safety, Field Director for Regulatory compliance/Fire Safety, and other staff escorting the surveyor during survey.

Based on observation, facility did not ensure that the buildings having staircase serving 5 or more stories ( such as Herbert Irving) had an identification sign complying with the elements as stated in NFPA 101 section 7.2.2.5.4.

Findings Include:

During the tour of the 13th Floor Herbert Irving pavilion on 04/16/13 at 3:00 PM, when staircase B was inspected it was noted that the sign identifying the staircase did not comply with the provision of NFPA 101 7.2.2.5.4.

Findings were verified with Director of Facilities, Director of Environmental and Heath Safety and other staff escorting the surveyor at the time of observation.

Note: NFPA 101 2000 7.2.2.5.4* Stair Identification Signs.
Stairs serving five or more stories shall be provided with signage within the enclosure at each floor landing. The signage shall indicate the story, the terminus of the top and bottom of the stair enclosure, and the identification of the stair enclosure. The signage also shall state the story of, and the direction to, exit discharge. The signage shall be inside the enclosure located approximately 5 ft (1.5 m) above the floor landing in a position that is readily visible when the door is in the open or closed position.

A. Based on document review and staff interview, it was determined that the hospital did not ensure that the sprinkler system maintenance/tests were done as per NFPA 13 and NFPA 25 to ensure that the system is in operating and reliable condition as per the codes.

Findings include:

On 04/18/13 from 11:00 AM to 4:00PM, during the document review of different buildings and campuses of the facility, the following was noted regarding the test and maintenance of the sprinkler system

i. A three year full Dry pipe valve flow test for the sprinkler systems was not provided for Milstein or any of the campuses/building of the facility. Only partial annual trip test reports were provided. A full dry pipe trip test of sprinkler system is required by NFPA 25 1998 9-1.

ii. During the review for the sprinkler test reports it was noted that there was no documentation or report available for the sprinkler system of Milstein or any other campuses/building to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves were conducted. It could also be not verified if the gauges were recalibrated or replaced in the past five years for the sprinkler systems of the different buildings/campuses.

Note: As per NFPA, there are two activities that are related to obstructions in Chapter 13 that require attention. The first is an investigation that is actually more of an "inspection" as described in Section 13.2.1 that must be conducted every five years. While the sprinkler system is shut down for the purpose of internal valve inspections (See Table 12.1), the flushing connection at the end of one cross main and a single sprinkler at the end of one branch line must be removed and the inside of the piping is then "inspected" for the presence of organic and inorganic material. In Section 13.2.2 a more comprehensive obstruction "investigation" must be conducted when any of the 14 conditions listed in that section are present. This more comprehensive obstruction "investigation" is conducted by internally examining the following four points in a system: system valve, riser, crossmain and, branchline.

iii. The facility did not have for all campuses/buildings the comparison of the static and residual pressure for the main drain test report. Furthermore, for main drain test report having low pressure (such as the report for Allen Building dated 02/20/13) there was no verification if it was compared against the hydraulic name plate and was acceptable/normal.

Findings were observed and verified with respective Director of Facilities/Supervisors of the campuses/buildings and Director of Corporate Management Services..

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


Findings include:

During the tour of the 7th floor of Eye Institute on 04/22/13 between 11:45AM, it was observed that the exposed sprinkler pipes in various areas of the floor exhibited accumulation of lint, dust and dirt

Note: Section 2-2.1.1* of NFPA 25 states that, "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

All findings were observed and verified with Director of Environmental and Health Safety, Director of Facilities and other staff escorting the surveyor during survey.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such 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:

During survey of facility from 04/15/13 to 04/23/13 from 10:30AM to 3:45PM, it was noted that in various floors of the different buildings of the facility, the fire extinguishers were installed ( such as the one in Emergency Department, one to ICU-Medicine A) on the wall or in the recess cabinet is such a way that its topmost portion was greater than the required 5 ft. (60 inches).

All findings for high extinguishers were observed and verified with Director of Environmental and Health Safety, Director of Facilities, and Field Director Regulatory Compliance/Fire Safety.

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

The findings were:

During the tour of different parts of the facility from 04/15/13 to 04/23/13 between 10:45 AM to 4:00PM, impediments in the path and means of egress were noted.

i. On 04/15/13 at 12:00 PM , during a tour of the OR suite (4th floor Milstein) it was noted that the alcove/corridor in the rear exit from the suite ( outside the perfusion room) was blocked by a big garbage receptacle, turnover cart and housekeeping cart. These items were placed as such that in case of emergency the stretcher for the patients cannot be freely rolled out the exit as they will provide hindrance and were blocking the path of egress.


ii. On 04/16/13 at 12:30 PM, during the tour of Medicine ICU-A(4th floor Milstein Hospital) it was noted that the corridors/path of egress of the suite was cluttered with different equipments and chairs. This arrangement creates an impediment in the path of egress/means of egress to reach the exit corridor in case of fire.

iii. On 04/16/13 at 3:00 PM, during the tour of the Endoscopy suite in the Herbert Irving building, it was noted that there were stretchers outside the Endoscopy rooms in the exit corridors. Thus this arrangement was obstructing the corridor for easy access during fire emergency.
All findings were observed and verified with Director of Environmental and Health Safety, Director of Facilities, and other staff escorting the surveyor during survey.

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

The findings include:

During the survey from 04/15/13 10 04/23/13 between 1:00 AM to 4:00 PM, it was observed that the facility had provided decorative artificial plants about 4.0-5.0 feet tall in the lobby of the Milstein Building.

Furthermore on 04 /17/13 at 12:45PM, during the tour of the Rehabilitation Unit (8th floor-Milstein Building), it was noted that the Occupational Therapy room had artificial flowers and trees. An interview with Filed Director Regulatory Compliance/Fire Safety at the time of observations revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. He stated that he did not think that those plants were rendered flame retardant by any chemical treatment and stated that he will try to look for the specifications.

Therefore, no flame retardant verification was provided for the tall plants in the main lobby of Milstein or the plants of Occupational Therapy.

Based on observation in the different areas of the facility, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls and penetrations made through floors were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6

Findings include:

During the tour of the facility from 04/15/13 to 04/23/13 between 11:00 AM to 4:00 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected for the integrity of smoke barriers. The rated walls of different areas were also inspected for integrity. The penetrations made through one floor to the other in mechanical/electrical/it closets were also observed.

It was noted that the barriers and floors were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes. These penetrations were not completely sealed all around with an approved fire retardant material to prevent passage of smoke from one compartment to the other.

Examples, including but not limited to:


a. On 04/15/13 at 12:45PM, during the tour of the 3rd and 4th floor OR suite ( Milstein building), it was noted that above ceiling of the main fire/smoke barrier rated wall there were unsealed penetrations made by wires and cables

b. On 04/16/13 at 2:45 PM, during the tour of the Infusion Center (Herbert Irving) , it was noted that the electrical closet had miscellaneous penetrations of the fire rated wall with improperly sealed wires and pipes/conduits.

d. On 04/17/13 at 1:00 PM, penetrations were noted above the drop ceiling by smoke door ( near 6HS 202). The rated wall of the shaft had a hole. Penetrations were noted by double door of 6 HN 130.

c. On 04/19/13 at 2:45 PM during the tour of the Adult Emergency Department, the IT closet/rated shaft by VC #138 had penetrations to the corridor wall.

d. On 04/22/13 at 12:45PM, many penetrations were noted going through the floor to the electrical/IT room above and the penetration was not sealed with any fire retardant material.

e. On 04/22/13 at 2:00PM, various penetrations made by wires, cables and some holes were noted in the fire/smoke barrier on the 3rd floor Heart Center ( connecting with Milstein) by bays 9 & 10.

Various other floor to floor or floor to corridor penetrations were noted in the electrical/IT closets of the various buildings of the facility. All observations and findings of the various sites of issues were verified with Director of Facilities, Director of Environmental and Health Safety , Field Director Regulatory Compliance/Fire Safety, and other engineering staff escorting the surveyor.

Note: Section 8.3.6.1 of NFPA 101 states that:

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

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

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

b. It shall be protected by an approved device that is designed for the specific purpose.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13 1999 [Standard for the Installation of Sprinkler Systems], to provide complete coverage in the fully sprinklered smoke compartment of CHONY Central-3rd floor.

Findings include:

On 04/24/13 at 12:15 PM during the tour of the Microbiology Laboratory on 3rd floor CHONY Central, it was noted that the laboratory is a part of a smoke compartment (as per the floor plan) and as per the staff the compartment is fully sprinklered.

A walk-in-cooler/refrigerator was noted not having any sprinkler head, thus the compartment is not fully sprinklered.

Findings were observed and verified with Director of Corporate Management Services and Director of Environmental and Health Services.

Based on staff interview, it was determined that the facility did not ensure that the elevators in the Milstein building were wired as per NFPA 99 3.4.2.2.2 to the life safety branch of Type I EES system

Findings include:

On 04/17/13 at 3:30 PM, during the tour of the mechanical room housing the ATS switches for the emergency generators, the staff/electrician was requested to provide information regarding what items were supplied by the life safety branch and critical branch of the emergency generator (a conclusion could not be made by looking at the labels/directory of the ATS panels).

On 04/18/13 at 1:00 PM, the staff/electrician for the Milstein Building stated/confirmed that the lighting and cab of the elevators were not hooked up to the life safety branch of the Type 1 EES.

Note: As per the code NFPA 99 3.4.2.2.2 (b)(6), Elevator cab lighting, control, communication, and signal systems should be on life safety branch and not on the equipment branch. For the equipment branch of Type I EES, the code is:

Section 3.4.2.2.3(e) "Equipment for Delayed-Automatic or Manual Connection. The following equipment shall be arranged for either delayed-automatic or manual connection to the alternate power source [also see A-3-4.2.2.3(d)]:
(2)'Elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power [For elevator cab lighting, control, and signal system requirements, see 3-4.2.2.2(b)(6).]'.

Similar finding was brought to the attention of the surveyor for Allen Hospital/Building.
Findings were verified with respective Director of Facilities/Supervisors of the campuses/buildings and Director of Corporate Management Services.