HospitalInspections.org

Based on observations during the Life Safety Code survey, it was noted that structural components of the facility were not adequately protected from fire. Issues include structural steel /steel beams of the building not protected completely to meet minimum fire rated building construction of Type II (222).

Findings are:

During the survey from 04/10/15 to 04/20/15 between 11:00 AM to 3:15 PM, observations were made in the Mechanical room and other areas/mechanical areas where structural beams were visible from the floor level. During the observation of the Tisch Ancillary Machine room on 7th floor it was revealed that the I-beams and steel beams / steel web truss assemblies / steel supporting the weight of the deck above, in many places were not completely protected with a fire resistive material and thus exhibited big gaps devoid of fire spray.

Similar finding was noted in the Mechanical areas/room of Energy building on the 5th floor and elevator machine room. These ancillary areas serve the newly constructed Radiology floor in this building.

Findings were verified with Director of Facilities of the Tisch Buildings and other Staff accompanying the surveyor during the survey.

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

Based on observations, the facility did not ensure that all exit passageways are maintained free of obstruction or impediments to full and instant use, in the case of fire or other emergency as per NFPA 101 200 section. 7.1.10.1. Furthermore, NFPA 101 Sub-Section 7.5.1.1 requires that "Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times".

Findings include:

During the tour of the Central Sterile Supply Work room (CSSW) on 7th floor of Tish Building at 1:30 PM, it was noted that the Exit access corridor outside the entrance to the workroom had carts and shelves parked on both side of the corridor. The electric closet was also blocked.

Furthermore the Emergency exit from the CSSW had two carts and other equipment parked near it, thus constricting the access to the exit.

Such arrangement compromises the full instant use of the means of egress to the Exit.

Findings were verified at the time of observation with Director of Facilities, Director of Sterilization Department and Director or Peri-operative Surgeries.

Similar finding was noted on 04/14/15 at 12:00 PM on the 2nd floor HCC building. The corridor in the Radiology office leading to the Day surgery was not free of impediments. This corridor may also serve as emergency exit from the Day Surgery.

Based on document review and staff interview, the facility did not ensure that the fire drills were conducted under varying conditions and that planning / evaluation of fire drills were done as per NFPA 101.

Findings include:

A review of the fire drill record for HJD building on 04/20/15 at 11:45 AM indicated that the facility has instituted a checklist highlighting the points of the drill on which the staff conducting the drill/observer checks off "yes" or "no". During review at that time it was revealed that the fire drills did not include 'simulation of various types of emergency fire conditions' or fire drills 'under varying condition'. There was no evidence in the drills that the staff ensured how drills are executed successfully under the varying conditions and that each staff has a full and clear understanding of the situation and facility's fire safety plan.

The drills did not indicate what was staff's first response in various simulated scenarios in particular the one staff who discovers fire versus the other staff who hears the alarm or alert. Both situations require different steps to be taken as indicated in the following code:

NFPA 101 2000 section 20.7.2.3
All personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

Personnel hearing the code announced shall first activate the building fire alarm using the nearest fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Most of the fire drills were noted stating the first statement as "Fire Drill conductor unannounced activated the pull station" which as per the above code does not satisfy the varying conditions under which the drill should be performed and staff's response in discovering the emergency.

Above findings were verified with the Fire Safety Personnel responsible for drills in HJD building.

Based on document review and staff interview, it was determined that the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1.

Findings include:

1. On 04/17/15 at 11:30 AM, during documentation review for the sprinkler test for Cobble Hill Emergency Department, it was noted and verified by Director of Engineering that there are no documentation or report available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves were conducted. Furthermore, no verification was presented to verify if the gauges were recalibrated or replaced in the past five years.

Similar issues was noted for 5 year sprinkler test report for HJD building.

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.

2. Three year trip test for the Dry Sprinkler system was also not provided for Cobble Hill.

3. On 04/20/15 at 12:30 PM document and reports for five year 'Standpipe Hydrostatic test and Flow Test' were requested for HJD building and reviewed. Facility provided a document from Fire Department of New York (FDNY)] dated 07-07-2009

No other document was provided for the 5 year hydrostatic test for building indicating the test's compliance with code NFPA 25 1999 section 3-3.2.1 which states:
'Hydrostatic tests at not less than 200-psi (13.8-bar) pressure for 2 hours, or at 50 psi (3.4 bar) in excess of the maximum pressure, where maximum pressure is in excess of 150 psi (10.3 bar), shall be conducted every 5 years on dry standpipe systems and dry portions of wet standpipe systems'.

Director of Engineering stated that this test is conducted in presence of FDNY and witnessed by them, therefore, it was thought to be sufficient. It is to be noted that the document clearly states that the 'test' is in accordance with the Department's/FDNY regulation and does not state that the test is in lieu/alternative/equivalent/acceptable or in compliance as per NFPA 25.

Similar issue of Hydrostatic test not indicating 200 PSI for 2 hours was noted for Cobble Hill Emergency Department.

4. On 04/17/15 at 11:45 AM, during review of the annual 2014 main drain test report for the sprinkler systems for Cobble Hill Emergency Department it was noted that the report did not have the comparison of the static and residual pressure from the last year's report. Furthermore, the differences between the static and residual values were more than 25 PSI and it could not be determined if this pressure difference is normal for the sprinkler system and is as per its hydraulic plate information or it does not meet the hydraulic plate requirement.


5. During the tour of the HJD Building on 04/14/15 at 12:30 PM, it was observed that the recessed sprinkler head cap on 9th floor by the elevator lobby, was completed painted over and no gap was left for the sprinkler spray pattern to reach fire in case of emergency.

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."

2-2.1.2* Unacceptable obstructions to spray patterns shall be corrected.

All above findings were verified with Director of Facilities, Assistant Project Manager and Director of Engineering/Facilities Managers of the respective sites.

Based on documentation review and staff interview, the facility did not ensure that all duct openings/penetrations made by the ventilation system in the rated barrier were equipped with fire/smoke dampers where required; and that all smoke/ fire dampers installed in the building at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair and installed in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

1. On 04/20/15 at 12:00 PM, during review of the last fire/smoke damper assessment of the HJD building dated 02/25/2009, it was noted that there were many areas where dampers were noted missing. For example, floor C1 in HJD had approximately 8 areas where it was written that there is no fire/smoke damper and the opening is for outside air coming in.

As per the Facilities Manager, two ventilation openings in location #C1-045 and C1-046 did have a fire/smoke damper. Since the report of 2009 did not show dampers in the above mentioned areas and of them being tested, Director of Engineering was requested to provide more information about the testing of those dampers and confirmation if any other area indicated in the report as devoid of damper, actually did have a damper.

A follow up report or work order that would show above information was not available and was not presented to the Survey Team.

Findings were verified with the Director of Engineering of HJD and Director of Facilities.

Based on observation and staff interview it was determined that the facility did not maintain the line pressure of the piped in medical gas system as per NFPA 99 in Operating Suite of the HJD buildings.

Findings include:

During the survey of the Operating Room Suite on SC1-HJD buildings from on 04/20/15 at 2:45 PM, it was noted that the oxygen pressure reading on the medical gas alarm panels in the PACU was reading 48 PSI and 49 PSI. It is to be noted that as per NFPA 99, Table 4-3.1.2.4, the standard line pressure for oxygen delivery to be maintained is 50 PSI (+5 and -0).

Findings were verified with Director of Engineering and Facilities Manager who stated that they will ensure that the pressure is raised to the required level.

A. Based on observation and staff interview, the facility did not ensure that the TYPE 1 Essential Electrical System (EES) wiring for three branches of Emergency Generator in Cobble Hill Emergency Department was done as per NFPA 99 3.4.2.2.2 and thus did not ensure that anything that is not required to be wired to Life Safety is accurately wired to either Critical Branch or Equipment Branch.

Findings include:

1. On 04/16/15 at 3:00 PM, during the tour of the Cobble Hill Emergency Department, the Director of Engineer of that place was questioned regarding the location of the emergency electrical panels.

Panel boards labeled #LS-1A and LCE-1ERSEC1 located in an alcove, surveyor was told were emergency branch panels .

In reviewing the directory of LS-1A it was noted that there was wiring for the lights at nurse's station, adult waiting and MGAP (which could not be identified what it was). As per the staff this was the Life Safety Branch panel.

Note: As per NFPA 99 Section 3-4.2.2.2
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101, ® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems."
4. Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.

NOTE: No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

Furthermore LCE-1ER SEC1 had Medical Gas alarm panel. As per staff this panel was the critical branch panel, and thus the medical gas alarm should have been connected to the Life Safety Branch.

Therefore, it was concluded that this panel has mixed wiring and is not wired as per TYPE 1 EES.

All above findings were verified with and Director of Facilities, Director of Engineering and Assistant Project Manager.

1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.


B. Based on staff interview and document review, the facility failed to maintain the emergency generators in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4 and NFPA 110 thus allowing it to transfer in 10 seconds.

Findings include.

On 04/17/15 at 11:15 AM, during documentation review of the emergency generator monthly load test logs for Cobble Hill Emergency Department, it was noted that there was no transfer time information for the transfer switches on emergency generators.

To meet state and Federal licensure requirements, healthcare facilities must exercise their emergency generators under load at least monthly, and time delays must be set as follows:
a. Time delay on start: 1 second minimum.*
Exception: Gas turbine cycle: 0.5 second minimum.
*Note: NFPA 101(00), Sec. 7.9.1.2 requires that emergency loads be picked up within 10 seconds.
Based on the review of facility's logs it could not be revealed if the generators meet the above guidelines since there was no transfer time or load pick up time indicated in the logs.
Note: It is important to verify that the emergency generator is capable of transferring the load as per the following requirements of every monthly load test:

NFPA 99 1999 - 3-4.3 Performance Criteria and Testing (Type 1 EES).
3-4.3.1 Source.
The branches of the emergency system shall be installed and connected to the alternate power source specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.

NFPA 99 1999- 3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1].

Findings were verified with Director of Facilities and Engineering Personnel of Cobble Hill.

A. 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 9th floor HCC building and 9th floor HJD building's newly renovated side.

Findings include:

On 04/14/15 at 12:30 PM during the tour of the 9th floor-Cardiac Rehab unit in HCC building, it was noted that the electrical closet did not have any sprinkler head. The suite as per floor plan and Director of Facilities is fully sprinklered. The closet also did not have a 2 hour rated wall shown on the floor plan nor had a door tag indicating the rating.

Similar issue was noted on 04/17/15 at 2:00 PM on the 9th floor- Rehab in HJD building

It is to be noted that NFPA 13, section 5-13.1.1* states that:
"All concealed spaces enclosed wholly or partly by exposed combustible construction shall be protected by sprinklers".

Closets are part of the building structure, which have the walls, ceiling, and floor generally made of the same construction materials as the building. Closets are required to be sprinklered in order for the space/suite to be considered fully sprinklered.

Findings were observed and verified with and Director of Environmental Health and Safety.

Based on staff interview and document review all electrical receptacles in patient care areas were not tested and maintained as per code.

Findings include:

On 04/20/15 at 12:30 PM, facility was requested to provide evidence that all electrical receptacles in the patient care areas in HJD building were tested.

Director of Engineering provided electrical receptacles testing only for GFCI receptacles. No report was available and provided for regular hospital grade receptacles in patient care areas.
NOTE: NFPA 1999 (99 ed) section 3-3.4.2.3 Maintenance and Testing of Electrical system Testing Interval for Receptacles in Patient Care Areas states that:

(1) Testing shall be performed after initial installation, replacement, or servicing of the device.

(2) Additional Testing shall be performed at intervals defined by documented performance data.

Furthermore, NFPA 99, 1999 Section 3-3.3.3 states the parameters for testing which are:
Receptacle Testing in Patient Care Areas
a. The physical integrity of each receptacle shall be confirmed by visual inspection.
b. The continuity of the grounding circuit in each electrical receptacle shall be verified.
c. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
d. The retention force of the grounding blade of each electrical receptacle, (except locking-type receptacles) shall be not less than 115 grams (115 g or 4 ounces).

Section 3-3.4.3.1 Record Keeping
A record shall be maintained of the tests required by this chapter and
associated repairs or modifications. At a minimum, this record shall contain date, the rooms or areas tested and an indication of which items have met or have failed to meet the performance requirements of the chapter.

Based on observations during the Life Safety Code survey, it was noted that structural components of the facility were not adequately protected from fire. Issues include structural steel /steel beams of the building not protected completely to meet minimum fire rated building construction of Type II (222).

Findings are:

During the survey from 04/10/15 to 04/20/15 between 11:00 AM to 3:15 PM, observations were made in the Mechanical room and other areas/mechanical areas where structural beams were visible from the floor level. During the observation of the Tisch Ancillary Machine room on 7th floor it was revealed that the I-beams and steel beams / steel web truss assemblies / steel supporting the weight of the deck above, in many places were not completely protected with a fire resistive material and thus exhibited big gaps devoid of fire spray.

Similar finding was noted in the Mechanical areas/room of Energy building on the 5th floor and elevator machine room. These ancillary areas serve the newly constructed Radiology floor in this building.

Findings were verified with Director of Facilities of the Tisch Buildings and other Staff accompanying the surveyor during the survey.

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

Based on observations, the facility did not ensure that all exit passageways are maintained free of obstruction or impediments to full and instant use, in the case of fire or other emergency as per NFPA 101 200 section. 7.1.10.1. Furthermore, NFPA 101 Sub-Section 7.5.1.1 requires that "Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times".

Findings include:

During the tour of the Central Sterile Supply Work room (CSSW) on 7th floor of Tish Building at 1:30 PM, it was noted that the Exit access corridor outside the entrance to the workroom had carts and shelves parked on both side of the corridor. The electric closet was also blocked.

Furthermore the Emergency exit from the CSSW had two carts and other equipment parked near it, thus constricting the access to the exit.

Such arrangement compromises the full instant use of the means of egress to the Exit.

Findings were verified at the time of observation with Director of Facilities, Director of Sterilization Department and Director or Peri-operative Surgeries.

Similar finding was noted on 04/14/15 at 12:00 PM on the 2nd floor HCC building. The corridor in the Radiology office leading to the Day surgery was not free of impediments. This corridor may also serve as emergency exit from the Day Surgery.

Based on document review and staff interview, the facility did not ensure that the fire drills were conducted under varying conditions and that planning / evaluation of fire drills were done as per NFPA 101.

Findings include:

A review of the fire drill record for HJD building on 04/20/15 at 11:45 AM indicated that the facility has instituted a checklist highlighting the points of the drill on which the staff conducting the drill/observer checks off "yes" or "no". During review at that time it was revealed that the fire drills did not include 'simulation of various types of emergency fire conditions' or fire drills 'under varying condition'. There was no evidence in the drills that the staff ensured how drills are executed successfully under the varying conditions and that each staff has a full and clear understanding of the situation and facility's fire safety plan.

The drills did not indicate what was staff's first response in various simulated scenarios in particular the one staff who discovers fire versus the other staff who hears the alarm or alert. Both situations require different steps to be taken as indicated in the following code:

NFPA 101 2000 section 20.7.2.3
All personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

Personnel hearing the code announced shall first activate the building fire alarm using the nearest fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Most of the fire drills were noted stating the first statement as "Fire Drill conductor unannounced activated the pull station" which as per the above code does not satisfy the varying conditions under which the drill should be performed and staff's response in discovering the emergency.

Above findings were verified with the Fire Safety Personnel responsible for drills in HJD building.

Based on document review and staff interview, it was determined that the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1.

Findings include:

1. On 04/17/15 at 11:30 AM, during documentation review for the sprinkler test for Cobble Hill Emergency Department, it was noted and verified by Director of Engineering that there are no documentation or report available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves were conducted. Furthermore, no verification was presented to verify if the gauges were recalibrated or replaced in the past five years.

Similar issues was noted for 5 year sprinkler test report for HJD building.

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.

2. Three year trip test for the Dry Sprinkler system was also not provided for Cobble Hill.

3. On 04/20/15 at 12:30 PM document and reports for five year 'Standpipe Hydrostatic test and Flow Test' were requested for HJD building and reviewed. Facility provided a document from Fire Department of New York (FDNY)] dated 07-07-2009

No other document was provided for the 5 year hydrostatic test for building indicating the test's compliance with code NFPA 25 1999 section 3-3.2.1 which states:
'Hydrostatic tests at not less than 200-psi (13.8-bar) pressure for 2 hours, or at 50 psi (3.4 bar) in excess of the maximum pressure, where maximum pressure is in excess of 150 psi (10.3 bar), shall be conducted every 5 years on dry standpipe systems and dry portions of wet standpipe systems'.

Director of Engineering stated that this test is conducted in presence of FDNY and witnessed by them, therefore, it was thought to be sufficient. It is to be noted that the document clearly states that the 'test' is in accordance with the Department's/FDNY regulation and does not state that the test is in lieu/alternative/equivalent/acceptable or in compliance as per NFPA 25.

Similar issue of Hydrostatic test not indicating 200 PSI for 2 hours was noted for Cobble Hill Emergency Department.

4. On 04/17/15 at 11:45 AM, during review of the annual 2014 main drain test report for the sprinkler systems for Cobble Hill Emergency Department it was noted that the report did not have the comparison of the static and residual pressure from the last year's report. Furthermore, the differences between the static and residual values were more than 25 PSI and it could not be determined if this pressure difference is normal for the sprinkler system and is as per its hydraulic plate information or it does not meet the hydraulic plate requirement.


5. During the tour of the HJD Building on 04/14/15 at 12:30 PM, it was observed that the recessed sprinkler head cap on 9th floor by the elevator lobby, was completed painted over and no gap was left for the sprinkler spray pattern to reach fire in case of emergency.

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."

2-2.1.2* Unacceptable obstructions to spray patterns shall be corrected.

All above findings were verified with Director of Facilities, Assistant Project Manager and Director of Engineering/Facilities Managers of the respective sites.

Based on documentation review and staff interview, the facility did not ensure that all duct openings/penetrations made by the ventilation system in the rated barrier were equipped with fire/smoke dampers where required; and that all smoke/ fire dampers installed in the building at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair and installed in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

1. On 04/20/15 at 12:00 PM, during review of the last fire/smoke damper assessment of the HJD building dated 02/25/2009, it was noted that there were many areas where dampers were noted missing. For example, floor C1 in HJD had approximately 8 areas where it was written that there is no fire/smoke damper and the opening is for outside air coming in.

As per the Facilities Manager, two ventilation openings in location #C1-045 and C1-046 did have a fire/smoke damper. Since the report of 2009 did not show dampers in the above mentioned areas and of them being tested, Director of Engineering was requested to provide more information about the testing of those dampers and confirmation if any other area indicated in the report as devoid of damper, actually did have a damper.

A follow up report or work order that would show above information was not available and was not presented to the Survey Team.

Findings were verified with the Director of Engineering of HJD and Director of Facilities.

Based on observation and staff interview it was determined that the facility did not maintain the line pressure of the piped in medical gas system as per NFPA 99 in Operating Suite of the HJD buildings.

Findings include:

During the survey of the Operating Room Suite on SC1-HJD buildings from on 04/20/15 at 2:45 PM, it was noted that the oxygen pressure reading on the medical gas alarm panels in the PACU was reading 48 PSI and 49 PSI. It is to be noted that as per NFPA 99, Table 4-3.1.2.4, the standard line pressure for oxygen delivery to be maintained is 50 PSI (+5 and -0).

Findings were verified with Director of Engineering and Facilities Manager who stated that they will ensure that the pressure is raised to the required level.

A. Based on observation and staff interview, the facility did not ensure that the TYPE 1 Essential Electrical System (EES) wiring for three branches of Emergency Generator in Cobble Hill Emergency Department was done as per NFPA 99 3.4.2.2.2 and thus did not ensure that anything that is not required to be wired to Life Safety is accurately wired to either Critical Branch or Equipment Branch.

Findings include:

1. On 04/16/15 at 3:00 PM, during the tour of the Cobble Hill Emergency Department, the Director of Engineer of that place was questioned regarding the location of the emergency electrical panels.

Panel boards labeled #LS-1A and LCE-1ERSEC1 located in an alcove, surveyor was told were emergency branch panels .

In reviewing the directory of LS-1A it was noted that there was wiring for the lights at nurse's station, adult waiting and MGAP (which could not be identified what it was). As per the staff this was the Life Safety Branch panel.

Note: As per NFPA 99 Section 3-4.2.2.2
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101, ® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems."
4. Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.

NOTE: No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

Furthermore LCE-1ER SEC1 had Medical Gas alarm panel. As per staff this panel was the critical branch panel, and thus the medical gas alarm should have been connected to the Life Safety Branch.

Therefore, it was concluded that this panel has mixed wiring and is not wired as per TYPE 1 EES.

All above findings were verified with and Director of Facilities, Director of Engineering and Assistant Project Manager.

1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.


B. Based on staff interview and document review, the facility failed to maintain the emergency generators in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4 and NFPA 110 thus allowing it to transfer in 10 seconds.

Findings include.

On 04/17/15 at 11:15 AM, during documentation review of the emergency generator monthly load test logs for Cobble Hill Emergency Department, it was noted that there was no transfer time information for the transfer switches on emergency generators.

To meet state and Federal licensure requirements, healthcare facilities must exercise their emergency generators under load at least monthly, and time delays must be set as follows:
a. Time delay on start: 1 second minimum.*
Exception: Gas turbine cycle: 0.5 second minimum.
*Note: NFPA 101(00), Sec. 7.9.1.2 requires that emergency loads be picked up within 10 seconds.
Based on the review of facility's logs it could not be revealed if the generators meet the above guidelines since there was no transfer time or load pick up time indicated in the logs.
Note: It is important to verify that the emergency generator is capable of transferring the load as per the following requirements of every monthly load test:

NFPA 99 1999 - 3-4.3 Performance Criteria and Testing (Type 1 EES).
3-4.3.1 Source.
The branches of the emergency system shall be installed and connected to the alternate power source specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.

NFPA 99 1999- 3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1].

Findings were verified with Director of Facilities and Engineering Personnel of Cobble Hill.

A. 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 9th floor HCC building and 9th floor HJD building's newly renovated side.

Findings include:

On 04/14/15 at 12:30 PM during the tour of the 9th floor-Cardiac Rehab unit in HCC building, it was noted that the electrical closet did not have any sprinkler head. The suite as per floor plan and Director of Facilities is fully sprinklered. The closet also did not have a 2 hour rated wall shown on the floor plan nor had a door tag indicating the rating.

Similar issue was noted on 04/17/15 at 2:00 PM on the 9th floor- Rehab in HJD building

It is to be noted that NFPA 13, section 5-13.1.1* states that:
"All concealed spaces enclosed wholly or partly by exposed combustible construction shall be protected by sprinklers".

Closets are part of the building structure, which have the walls, ceiling, and floor generally made of the same construction materials as the building. Closets are required to be sprinklered in order for the space/suite to be considered fully sprinklered.

Findings were observed and verified with and Director of Environmental Health and Safety.

Based on staff interview and document review all electrical receptacles in patient care areas were not tested and maintained as per code.

Findings include:

On 04/20/15 at 12:30 PM, facility was requested to provide evidence that all electrical receptacles in the patient care areas in HJD building were tested.

Director of Engineering provided electrical receptacles testing only for GFCI receptacles. No report was available and provided for regular hospital grade receptacles in patient care areas.
NOTE: NFPA 1999 (99 ed) section 3-3.4.2.3 Maintenance and Testing of Electrical system Testing Interval for Receptacles in Patient Care Areas states that:

(1) Testing shall be performed after initial installation, replacement, or servicing of the device.

(2) Additional Testing shall be performed at intervals defined by documented performance data.

Furthermore, NFPA 99, 1999 Section 3-3.3.3 states the parameters for testing which are:
Receptacle Testing in Patient Care Areas
a. The physical integrity of each receptacle shall be confirmed by visual inspection.
b. The continuity of the grounding circuit in each electrical receptacle shall be verified.
c. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
d. The retention force of the grounding blade of each electrical receptacle, (except locking-type receptacles) shall be not less than 115 grams (115 g or 4 ounces).

Section 3-3.4.3.1 Record Keeping
A record shall be maintained of the tests required by this chapter and
associated repairs or modifications. At a minimum, this record shall contain date, the rooms or areas tested and an indication of which items have met or have failed to meet the performance requirements of the chapter.