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Citation Text for Tag 0012, Regulation K201, Bld 01

Based on observations during a Life Safety Code survey, it was noted that structural components of the facility were not properly protected from fire. Issues include structural steel/steel beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type II (222) and Type I (332).

Findings include:

During tour observations of the Andrus, Park Care, and Dobbs Ferry Pavilions from 03/22/11 to 03/25/11 between 11:00 AM to 4:00 PM it was noted that the ceiling assembly located throughout the buildings is comprised of lay-in ceiling tiles. Observations above the suspended ceiling revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above, were not protected with a fire resistive material.
Examples of some unprotected I-beams including, but not limited to, are:
i. I-beam in the electrical closet #2 of the Radiology department (Andrus).
ii. I-beam by ICU room #15 (Andrus).
iii. I-beam in telephone closet (Park Care)
iv. I-beam in the Soiled Utility room of 2nd floor (Dobbs Ferry).
v. I-beam outside the OR suite (Andrus)

Findings were verified with Staff #25 and Staff #26.
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 did not comply with the above code requirements in that the facility's staircase landings (which have open sides and are more than 30 inches above the floor below) are not provided with guards which have intermediate rails or an ornamental pattern such that a sphere 4 inches (10.1cm) in diameter cannot pass through any openings. This was noted in staircases of Dobbs Ferry Pavilion.

Findings include:

On 03/24/11 at 2:45pm, it was observed that the guardrails provided at the landings of staircase in the Med Surg floor, are provided with the horizontal guard rails, approximately 8-9 inches apart from each other and the landings. This is in excess of the maximum 4 inches permitted by the code. There are no intermediate rails or other ornamental pattern for safety installed in accordance with NFPA 101, 7.2.2.4.6.

Findings were verified with Staff #30.

Note: Subsection 7.2.2.4.6 (Guard Details) of NFPA 101, requires that:
(1) The height of guards required in 7.2.2.4.1 shall be measured vertically to the top of the guard from the surface adjacent thereto.
(2) Guards shall be not less than 42 in. (107 cm) high.
Exception No. 1: Existing guards within dwelling units shall be permitted to be not less than 36 in. (91 cm) high.
Exception No. 2: The requirement of 7.2.2.4.6(2) shall not apply where otherwise provided in Chapters 12 and 13.
Exception No. 3*: Existing guards on existing stairs shall be permitted to be not less than 30 in. (76 cm) high.
(3) Open guards, other than approved, existing open guards, shall have intermediate rails or an ornamental pattern such that a sphere 4 in. (10.1 cm) in diameter shall not pass through any opening up to a height of 34 in. (86 cm).
Exception No. 1: The triangular openings formed by the riser, tread, and bottom element of a guardrail at the open side of a stair shall be of such size that a sphere 6 in. (15.2 cm) in diameter shall not pass through the triangular opening.
Exception No. 2: In detention and correctional occupancies, in industrial occupancies, and in storage occupancies, the clear distance between intermediate rails, measured at right angles to the rails, shall not exceed 21 in. (53.3 cm).

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

Findings include:

Staff #25 was requested on 03/25/11 at 12:15 PM to provide information regarding 90 minute yearly emergency battery back up light tests for the offsite locations. Staff #25 stated that he did not have those reports/documents and was not aware if the off-site locations were conducting these tests regularly.

Furthermore, no 90 minute test report was available for the emergency battery back up lights installed in the generator rooms at the three hospital campuses.

Note: 2000 LSC NFPA 101 Chapter 7.9.3 states that an annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspections by the authority having jurisdiction.

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

Findings include:

1. During fire drill record review on 03/21/11 at 03:15 PM, it was noted that the fire drill report of the facility is in the form of a checklist which is incomplete and highlights only a few points of the drill on which the 'observer' of the drill checks off "yes" or "no". Although the facility's fire drill records included staff sign-in sheets and brief comments, the facility failed to report/document a detailed critique in the records regarding staff's fire drill response and knowledge of evacuation procedure, to ensure staff is fully aware of fire drill/evacuation protocols .

Staff #25 stated that this was the format for all the campuses of the facility.

2.a. Review of fire drill records indicated that although the hospital's fire drills include transmission of a fire alarm signal, the hospital failed to conduct fire drills which include simulation of various types of emergency fire conditions to ensure that each staff has a full and clear understanding of facility's fire safety plan and how to execute it successfully under the varying conditions.

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

Findings were confirmed with Staff #25.

3. Based on review of the facility's annual mandatory inservice online program on 03/28/11 at 11:00 AM, it was noted that the annual mandatory course does not contain information on how to use/operate fire extinguishers and the execution of evacuation plans.

A. Based on staff interview and record review, it was determined that the facility did not ensure that the smoke detection system is maintained in reliable condition and good repair as per NFPA 101 2000 9.6.1.4 AND NFPA 72.

The findings include:

1. On 03/24/11 at 11:45 AM, during review of the fire/smoke detector test report (for Park Care Pavilion) from FSI, dated 10/18/10, it was noted that the work summary stated that the "System was in trouble upon arrival" and "was in trouble upon departure". Staff #26 was not aware of this issue and what sort of trouble was being registered in the system; therefore, there was no follow-up to this report to indicate if the issue was corrected.

B. Based on record review and interview, the hospital did not ensure that the sensitivity test is performed on all smoke detectors and the system is maintained in accordance with NFPA 72.

Findings include:

On 03/24/11 at 2:30 PM, during document review of the fire alarm test reports, Staff #26 was requested to indicate/provide the reports for the sensitivity test of all the smoke detectors in the Andrus, Park Care, and Dobbs Ferry Pavilions, and the off-site extension clinics. For the Andrus Pavilion, Staff #26 stated that some of the detectors are addressable and thus they come automatically on the fire alarm panel; however, some detectors were non-addressable. No report of the non-addressable smoke detectors was provided for the Andrus and Park Care Pavilions.

Note: Section -7-3.2.1* NFPA 72 requires that
detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method;
(2) Manufacturer's calibrated sensitivity test instrument;
(3) Listed control equipment arranged for the purpose;
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit to indicate if its sensitivity is outside its listed sensitivity range;
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction;
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and re-calibrated or be replaced.

A. Based on document review and staff interview, it was determined that the hospital did not ensure that the sprinkler system was maintained in operating and reliable condition as per NFPA 13 and NFPA 25.

Findings include:

1. On 03/22/11 at 3:15 PM, facility provided the annual sprinkler report for the Andrus Pavilion dated 03/01/11. The report stated that 'See attached sheet for Problems/violations'. Facility did not provide surveyor with problems, issues identified at this time. Staff #26 stated that since this was done recently, it takes time for the vendor to submit the full report.

2. The report previous to this one dated 10/12/10 indicated several alarm, tamper, and flow switch issues. An inspection cover sheet was provided indicating 17 issues in total. No follow-up to this report was provided to determine if facility corrected these issues, if the issues are still existing and if so, how has the facility ensured the safety of the building and its occupants.

Findings were confirmed by Staff #25 and Staff #26.

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

Findings include:

1.a. On 03/22/11 at 3:30 PM, during documentation review for the Andrus Pavilion and staff interview with Staff #25 and Staff #26, it was revealed that no documentation was available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves and associated trim and check valves were conducted. Also, it could not be verified if the gauges were recalibrated/replaced in the past five years.

1.b. On 03/28/11 at 12:00 PM, Staff #25 provided a report dated 09/28/07 in lieu of 5 year report. However, this report was missing information on alarm check, gauges' recalibration, internal pipe review and other requirements.

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. Furthermore, no 5 year report was provided for Park Care Pavilion and all off-site locations. A report for Greenburgh Alcohol Services, dated 12/07/10, indicated a 5 year check; however, page #2 did not have information for gauges being recalibrated/replaced. For all the other sites, only documents/reports for quarterly/monthly sprinkler inspection were provided.

C. 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 Park Care Pavilion from 03/23/11 to 03/24/11 from 11:00 AM to 3:30 PM, it was observed that the exposed sprinkler pipes in various locations on the ground level (near methadone clinic) and Dental Clinic exhibited accumulation of lint/dust /and paint specks.

Findings were verified with Staff #26.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed in such a manner that they are not obstructed and are readily accessible during a fire situation as per NFPA 101 9.7.4.1.

Findings include:

1. During an observation tour of the kitchen in Andrus Pavilion on 03/28/11 at 11:00 AM, it was observed that two fire extinguishers were blocked by a food cart. The finding was verified with Staff #1.

2. During the tour of the Greenburgh Alcoholism Extension Clinic on 03/24/11 at 3:30 PM, it was noted a stack of 7-8 chairs were blocking the fire extinguisher in the Group room by the offices.

Findings were verified with Staff #25 and Staff #26.

Note: Section 1-6.3 of NFPA 10 states that
fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

Based on documentation review for Andrus, Park Care, and Dobbs Ferry Pavilions and staff interview, it was determined that the facility failed to ensure that all fire dampers installed at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair, and in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

1. On 03/23/11 at 11:45 AM, it was determined that the facility has equipped the three campuses with fire/smoke dampers at the ventilation ducts openings/penetrations through the smoke/fire barriers. A review of the fire/smoke dampers inspection report for Andrus Pavilion, conducted in the year 2009, revealed that out of 458 dampers, at least 52 dampers were defective or were needed; 63 were unaccessible; and for 33, access was needed
for the inspecting staff.

In an interview at that time, Staff #26 stated that facility has identified these problems and has contracted 'C & S Building Services' to work on their correction. A copy of proposal from the company 'C & S ' dated 09/16/2010 was provided to the surveyor that indicated the scope of work. However, the document did not have the facility (St.John's) signature on it to indicate whether it was approved or not; and there was no expected date of completion provided to the surveyor.

Furthermore, no information was provided if interim fire safety/ fire watch program had been in effect at the premises, pending the replacement of the dampers.

Findings were verified with Staff #25 and Staff #26 at the time of review.

2. On 03/23/11 at 11:45 AM, similar findings were noted in the smoke damper report dated 2009 for Park Care Pavilion which indicated 15 deficiencies all together. A follow-up work order was provided that indicated dates on 03/2009 and 12/2009. Out of 15 issues, 9 were solved and no follow-up was provided for the remaining 6 deficiencies which mostly included blocked or unavailable access.

3. On 03/24/11 at 2:30 PM, the fire/smoke damper work order report for Dobbs Ferry Pavilion, dated 2006, indicated that 9 deficiencies were not resolved, which included 3 out of reach dampers; 5 dampers not there as per print; and 1 damper blocked by plumbing.

Findings were verified with Staff #25, Staff #26 and Staff #30.

Based on document review, it was determined that the facility did not ensure that the inspection reports of the kitchen hoods at Andrus Pavilion were reviewed to ensure compliance.

Findings include:

On 03/28/11 at 11:45 AM, a review of the kitchen hood report from 'Interstate Fire & Safety Equipment Company, Inc', dated 11/11/10, indicated the following:
i. Grease build up around the hood, filters, fan and ducts were heavy. This was noted in all 4 reports of 2010.

ii. In the section 'Do fire system nozzles have caps?' the answer is No. However, in the reports of 01/10 and 04/10 the answer was Yes. In the report of 08/10, the answer was left blank.

iii. In the section 'Does the duct have mineral wool sleeves or insulations where penetrations are made. The answer was NO. Also, the previous report of 08/11 had a question mark against this section whereas in 04/10 the answer was YES. This indicates that over time the mineral wool came off and no action was taken.

iv. In the section 'Does the duct system have proper access doors/'. The answer provided was NO. In the subsequent section, the report asks 'Does the system require additional access door? Report stated YES; however, no quantity was given. This was seen in the last three reports.

Staff #25 and Staff #26 were interviewed but were not aware of answers to the questions asked. Staff #26 tried to contact the vendor to find out what these things meant and if they compromised the kitchen hood system in anyway. No answer for any corrective action was provided to the surveyor.

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

Findings include:

On 03/24/11 at 3:30 PM during the review of the medical gas report of Andrus Pavilion from 'MMS' dated June 2010, it was noted that the report indicated 69 repair deficiencies, 15 Alarm Failures, 1 leak (Recovery Area) and 13 dead outlets. Out of these deficiencies, corrective action follow-up was provided for only 69 repair deficiencies in the work order of 12/23/2010. No follow-up was provided regarding the other deficiencies in the report.

Findings were confirmed with Staff #25 and Staff #26.

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

Findings include:

1. During the tour of the Andrus, Park Care and Dobbs Ferry Pavilions between 03/21/11 to 03/25/11 from 12:45 PM to 3:45 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected to see the integrity of smoke barriers. It was noted that the smoke barriers 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, are:
a. The double door near the OR suite (Andrus) had wires/HVAC duct/conduit passing through with missing/incomplete fire retardant material all around them.

b. The double door near the ICU suite (Andrus) had different color material around the penetrating pipes/cables/wires. The colors such as pink, grey and white/cream joint compound were noted. The UL rating of these different colored filling material could not be determined/verified at the time of survey.

c. The two hour fire wall by the Endoscopy suite (Andrus) had copper colored wire penetrating without fire retardant completely sealing it all around.

d. The smoke/fire barrier on the 4th floor (Park Care) exhibited big penetrations/holes in the above drop ceiling wall and it was not patched/filled with any fire retardant material.

e. The smoke/fire barriers on the 2nd floor and by the Central Sterile Processing room (Dobbs Ferry) exhibited penetrations sealed by Polyurethane Foam. Foam is not considered an approved UL rated material to be used in smoke/fire barriers.
Use of foam as sealant was also noted in the fire-rated walls of the emergency generator room (Dobbs Ferry) and chiller room (Andrus).

This finding was verified with Staff #25 and Staff #26 at the time of observation.

2. It was noted that in the Electrical/data room of the Radiology Suite (Andrus), there were pipes/conduits/cables/waste lines penetrating the wall and lacking complete fire retardant all around. Furthermore, the head of the wall joined with the ceiling/deck exhibited gaps which were not filled with any fire retardant material. A similar finding was noted in almost all electrical closets of the three pavilions.

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.

A. Based on observation, it was determined that the facility failed to provide a battery back up light in the 650 K generator room in the Andrus Pavilion.

Findings include:

On 03/22/11 at 2:30 PM, it was noted that the generator room/trailer, housing the 650K generator, did not have an emergency battery powered back up light. The finding was verified with Staff #25 and Staff #26.

Note: Subsection 5-3.1 of NFPA 110 requires that:
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

B. Based on observation, it was determined that the facility failed to ensure that the generator room in Dobbs Ferry is not used for storage purposes.

Findings include:

On 03/24/11 at 2:00 PM, it was noted that the generator room in Dobbs Ferry has abundant amount of furniture, cardboard boxes, and other similar combustible items stored along with the generator.

Finding was verified with Staff #25, Staff #26 and Staff #30.

Note: Subsection 5-11.1of NFPA 110 states that:
The room in which the EPS equipment is located shall not be used for storage purposes.

Based on observations and record review, it was noted that the facility provides general anesthesia in Andrus Pavilion.
(NFPA 99 - 1999 defines "Critical Care Areas" (i.e., Operating Rooms where NFPA 99 defined "invasive procedures" are performed and patients are connected to line operated patient care-related electrical appliances.)
Based on observation and staff interview, it was determined that the emergency generator 650kVA in the Andrus Pavilion was not wired as a Type I EES (essential electrical system). NFPA 99 3-4.

Findings include:

Based on interviews with Staff #25, staff suggested that the wiring configuration in the Andrus Pavilion for the Type I EES (650 K generator) may not be compliant with 1999 NFPA 99 3-4.2.2.1. The specific issue involved was the separation of the generator branches into a life safety, critical, and equipment system for the facility. Discussion revealed that the generator is as it was installed in 1980's. The facility operates a ventilator dependent unit and as such, requires a Type I EES.

Therefore, the wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System, and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch.

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

Citation Text for Tag 0012, Regulation K201, Bld 01

Based on observations during a Life Safety Code survey, it was noted that structural components of the facility were not properly protected from fire. Issues include structural steel/steel beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type II (222) and Type I (332).

Findings include:

During tour observations of the Andrus, Park Care, and Dobbs Ferry Pavilions from 03/22/11 to 03/25/11 between 11:00 AM to 4:00 PM it was noted that the ceiling assembly located throughout the buildings is comprised of lay-in ceiling tiles. Observations above the suspended ceiling revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above, were not protected with a fire resistive material.
Examples of some unprotected I-beams including, but not limited to, are:
i. I-beam in the electrical closet #2 of the Radiology department (Andrus).
ii. I-beam by ICU room #15 (Andrus).
iii. I-beam in telephone closet (Park Care)
iv. I-beam in the Soiled Utility room of 2nd floor (Dobbs Ferry).
v. I-beam outside the OR suite (Andrus)

Findings were verified with Staff #25 and Staff #26.
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 did not comply with the above code requirements in that the facility's staircase landings (which have open sides and are more than 30 inches above the floor below) are not provided with guards which have intermediate rails or an ornamental pattern such that a sphere 4 inches (10.1cm) in diameter cannot pass through any openings. This was noted in staircases of Dobbs Ferry Pavilion.

Findings include:

On 03/24/11 at 2:45pm, it was observed that the guardrails provided at the landings of staircase in the Med Surg floor, are provided with the horizontal guard rails, approximately 8-9 inches apart from each other and the landings. This is in excess of the maximum 4 inches permitted by the code. There are no intermediate rails or other ornamental pattern for safety installed in accordance with NFPA 101, 7.2.2.4.6.

Findings were verified with Staff #30.

Note: Subsection 7.2.2.4.6 (Guard Details) of NFPA 101, requires that:
(1) The height of guards required in 7.2.2.4.1 shall be measured vertically to the top of the guard from the surface adjacent thereto.
(2) Guards shall be not less than 42 in. (107 cm) high.
Exception No. 1: Existing guards within dwelling units shall be permitted to be not less than 36 in. (91 cm) high.
Exception No. 2: The requirement of 7.2.2.4.6(2) shall not apply where otherwise provided in Chapters 12 and 13.
Exception No. 3*: Existing guards on existing stairs shall be permitted to be not less than 30 in. (76 cm) high.
(3) Open guards, other than approved, existing open guards, shall have intermediate rails or an ornamental pattern such that a sphere 4 in. (10.1 cm) in diameter shall not pass through any opening up to a height of 34 in. (86 cm).
Exception No. 1: The triangular openings formed by the riser, tread, and bottom element of a guardrail at the open side of a stair shall be of such size that a sphere 6 in. (15.2 cm) in diameter shall not pass through the triangular opening.
Exception No. 2: In detention and correctional occupancies, in industrial occupancies, and in storage occupancies, the clear distance between intermediate rails, measured at right angles to the rails, shall not exceed 21 in. (53.3 cm).

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

Findings include:

Staff #25 was requested on 03/25/11 at 12:15 PM to provide information regarding 90 minute yearly emergency battery back up light tests for the offsite locations. Staff #25 stated that he did not have those reports/documents and was not aware if the off-site locations were conducting these tests regularly.

Furthermore, no 90 minute test report was available for the emergency battery back up lights installed in the generator rooms at the three hospital campuses.

Note: 2000 LSC NFPA 101 Chapter 7.9.3 states that an annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspections by the authority having jurisdiction.

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

Findings include:

1. During fire drill record review on 03/21/11 at 03:15 PM, it was noted that the fire drill report of the facility is in the form of a checklist which is incomplete and highlights only a few points of the drill on which the 'observer' of the drill checks off "yes" or "no". Although the facility's fire drill records included staff sign-in sheets and brief comments, the facility failed to report/document a detailed critique in the records regarding staff's fire drill response and knowledge of evacuation procedure, to ensure staff is fully aware of fire drill/evacuation protocols .

Staff #25 stated that this was the format for all the campuses of the facility.

2.a. Review of fire drill records indicated that although the hospital's fire drills include transmission of a fire alarm signal, the hospital failed to conduct fire drills which include simulation of various types of emergency fire conditions to ensure that each staff has a full and clear understanding of facility's fire safety plan and how to execute it successfully under the varying conditions.

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

Findings were confirmed with Staff #25.

3. Based on review of the facility's annual mandatory inservice online program on 03/28/11 at 11:00 AM, it was noted that the annual mandatory course does not contain information on how to use/operate fire extinguishers and the execution of evacuation plans.

A. Based on staff interview and record review, it was determined that the facility did not ensure that the smoke detection system is maintained in reliable condition and good repair as per NFPA 101 2000 9.6.1.4 AND NFPA 72.

The findings include:

1. On 03/24/11 at 11:45 AM, during review of the fire/smoke detector test report (for Park Care Pavilion) from FSI, dated 10/18/10, it was noted that the work summary stated that the "System was in trouble upon arrival" and "was in trouble upon departure". Staff #26 was not aware of this issue and what sort of trouble was being registered in the system; therefore, there was no follow-up to this report to indicate if the issue was corrected.

B. Based on record review and interview, the hospital did not ensure that the sensitivity test is performed on all smoke detectors and the system is maintained in accordance with NFPA 72.

Findings include:

On 03/24/11 at 2:30 PM, during document review of the fire alarm test reports, Staff #26 was requested to indicate/provide the reports for the sensitivity test of all the smoke detectors in the Andrus, Park Care, and Dobbs Ferry Pavilions, and the off-site extension clinics. For the Andrus Pavilion, Staff #26 stated that some of the detectors are addressable and thus they come automatically on the fire alarm panel; however, some detectors were non-addressable. No report of the non-addressable smoke detectors was provided for the Andrus and Park Care Pavilions.

Note: Section -7-3.2.1* NFPA 72 requires that
detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method;
(2) Manufacturer's calibrated sensitivity test instrument;
(3) Listed control equipment arranged for the purpose;
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit to indicate if its sensitivity is outside its listed sensitivity range;
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction;
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and re-calibrated or be replaced.

A. Based on document review and staff interview, it was determined that the hospital did not ensure that the sprinkler system was maintained in operating and reliable condition as per NFPA 13 and NFPA 25.

Findings include:

1. On 03/22/11 at 3:15 PM, facility provided the annual sprinkler report for the Andrus Pavilion dated 03/01/11. The report stated that 'See attached sheet for Problems/violations'. Facility did not provide surveyor with problems, issues identified at this time. Staff #26 stated that since this was done recently, it takes time for the vendor to submit the full report.

2. The report previous to this one dated 10/12/10 indicated several alarm, tamper, and flow switch issues. An inspection cover sheet was provided indicating 17 issues in total. No follow-up to this report was provided to determine if facility corrected these issues, if the issues are still existing and if so, how has the facility ensured the safety of the building and its occupants.

Findings were confirmed by Staff #25 and Staff #26.

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

Findings include:

1.a. On 03/22/11 at 3:30 PM, during documentation review for the Andrus Pavilion and staff interview with Staff #25 and Staff #26, it was revealed that no documentation was available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves and associated trim and check valves were conducted. Also, it could not be verified if the gauges were recalibrated/replaced in the past five years.

1.b. On 03/28/11 at 12:00 PM, Staff #25 provided a report dated 09/28/07 in lieu of 5 year report. However, this report was missing information on alarm check, gauges' recalibration, internal pipe review and other requirements.

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. Furthermore, no 5 year report was provided for Park Care Pavilion and all off-site locations. A report for Greenburgh Alcohol Services, dated 12/07/10, indicated a 5 year check; however, page #2 did not have information for gauges being recalibrated/replaced. For all the other sites, only documents/reports for quarterly/monthly sprinkler inspection were provided.

C. 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 Park Care Pavilion from 03/23/11 to 03/24/11 from 11:00 AM to 3:30 PM, it was observed that the exposed sprinkler pipes in various locations on the ground level (near methadone clinic) and Dental Clinic exhibited accumulation of lint/dust /and paint specks.

Findings were verified with Staff #26.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed in such a manner that they are not obstructed and are readily accessible during a fire situation as per NFPA 101 9.7.4.1.

Findings include:

1. During an observation tour of the kitchen in Andrus Pavilion on 03/28/11 at 11:00 AM, it was observed that two fire extinguishers were blocked by a food cart. The finding was verified with Staff #1.

2. During the tour of the Greenburgh Alcoholism Extension Clinic on 03/24/11 at 3:30 PM, it was noted a stack of 7-8 chairs were blocking the fire extinguisher in the Group room by the offices.

Findings were verified with Staff #25 and Staff #26.

Note: Section 1-6.3 of NFPA 10 states that
fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

Based on documentation review for Andrus, Park Care, and Dobbs Ferry Pavilions and staff interview, it was determined that the facility failed to ensure that all fire dampers installed at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair, and in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

1. On 03/23/11 at 11:45 AM, it was determined that the facility has equipped the three campuses with fire/smoke dampers at the ventilation ducts openings/penetrations through the smoke/fire barriers. A review of the fire/smoke dampers inspection report for Andrus Pavilion, conducted in the year 2009, revealed that out of 458 dampers, at least 52 dampers were defective or were needed; 63 were unaccessible; and for 33, access was needed
for the inspecting staff.

In an interview at that time, Staff #26 stated that facility has identified these problems and has contracted 'C & S Building Services' to work on their correction. A copy of proposal from the company 'C & S ' dated 09/16/2010 was provided to the surveyor that indicated the scope of work. However, the document did not have the facility (St.John's) signature on it to indicate whether it was approved or not; and there was no expected date of completion provided to the surveyor.

Furthermore, no information was provided if interim fire safety/ fire watch program had been in effect at the premises, pending the replacement of the dampers.

Findings were verified with Staff #25 and Staff #26 at the time of review.

2. On 03/23/11 at 11:45 AM, similar findings were noted in the smoke damper report dated 2009 for Park Care Pavilion which indicated 15 deficiencies all together. A follow-up work order was provided that indicated dates on 03/2009 and 12/2009. Out of 15 issues, 9 were solved and no follow-up was provided for the remaining 6 deficiencies which mostly included blocked or unavailable access.

3. On 03/24/11 at 2:30 PM, the fire/smoke damper work order report for Dobbs Ferry Pavilion, dated 2006, indicated that 9 deficiencies were not resolved, which included 3 out of reach dampers; 5 dampers not there as per print; and 1 damper blocked by plumbing.

Findings were verified with Staff #25, Staff #26 and Staff #30.

Based on document review, it was determined that the facility did not ensure that the inspection reports of the kitchen hoods at Andrus Pavilion were reviewed to ensure compliance.

Findings include:

On 03/28/11 at 11:45 AM, a review of the kitchen hood report from 'Interstate Fire & Safety Equipment Company, Inc', dated 11/11/10, indicated the following:
i. Grease build up around the hood, filters, fan and ducts were heavy. This was noted in all 4 reports of 2010.

ii. In the section 'Do fire system nozzles have caps?' the answer is No. However, in the reports of 01/10 and 04/10 the answer was Yes. In the report of 08/10, the answer was left blank.

iii. In the section 'Does the duct have mineral wool sleeves or insulations where penetrations are made. The answer was NO. Also, the previous report of 08/11 had a question mark against this section whereas in 04/10 the answer was YES. This indicates that over time the mineral wool came off and no action was taken.

iv. In the section 'Does the duct system have proper access doors/'. The answer provided was NO. In the subsequent section, the report asks 'Does the system require additional access door? Report stated YES; however, no quantity was given. This was seen in the last three reports.

Staff #25 and Staff #26 were interviewed but were not aware of answers to the questions asked. Staff #26 tried to contact the vendor to find out what these things meant and if they compromised the kitchen hood system in anyway. No answer for any corrective action was provided to the surveyor.

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

Findings include:

On 03/24/11 at 3:30 PM during the review of the medical gas report of Andrus Pavilion from 'MMS' dated June 2010, it was noted that the report indicated 69 repair deficiencies, 15 Alarm Failures, 1 leak (Recovery Area) and 13 dead outlets. Out of these deficiencies, corrective action follow-up was provided for only 69 repair deficiencies in the work order of 12/23/2010. No follow-up was provided regarding the other deficiencies in the report.

Findings were confirmed with Staff #25 and Staff #26.

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

Findings include:

1. During the tour of the Andrus, Park Care and Dobbs Ferry Pavilions between 03/21/11 to 03/25/11 from 12:45 PM to 3:45 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected to see the integrity of smoke barriers. It was noted that the smoke barriers 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, are:
a. The double door near the OR suite (Andrus) had wires/HVAC duct/conduit passing through with missing/incomplete fire retardant material all around them.

b. The double door near the ICU suite (Andrus) had different color material around the penetrating pipes/cables/wires. The colors such as pink, grey and white/cream joint compound were noted. The UL rating of these different colored filling material could not be determined/verified at the time of survey.

c. The two hour fire wall by the Endoscopy suite (Andrus) had copper colored wire penetrating without fire retardant completely sealing it all around.

d. The smoke/fire barrier on the 4th floor (Park Care) exhibited big penetrations/holes in the above drop ceiling wall and it was not patched/filled with any fire retardant material.

e. The smoke/fire barriers on the 2nd floor and by the Central Sterile Processing room (Dobbs Ferry) exhibited penetrations sealed by Polyurethane Foam. Foam is not considered an approved UL rated material to be used in smoke/fire barriers.
Use of foam as sealant was also noted in the fire-rated walls of the emergency generator room (Dobbs Ferry) and chiller room (Andrus).

This finding was verified with Staff #25 and Staff #26 at the time of observation.

2. It was noted that in the Electrical/data room of the Radiology Suite (Andrus), there were pipes/conduits/cables/waste lines penetrating the wall and lacking complete fire retardant all around. Furthermore, the head of the wall joined with the ceiling/deck exhibited gaps which were not filled with any fire retardant material. A similar finding was noted in almost all electrical closets of the three pavilions.

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.

A. Based on observation, it was determined that the facility failed to provide a battery back up light in the 650 K generator room in the Andrus Pavilion.

Findings include:

On 03/22/11 at 2:30 PM, it was noted that the generator room/trailer, housing the 650K generator, did not have an emergency battery powered back up light. The finding was verified with Staff #25 and Staff #26.

Note: Subsection 5-3.1 of NFPA 110 requires that:
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

B. Based on observation, it was determined that the facility failed to ensure that the generator room in Dobbs Ferry is not used for storage purposes.

Findings include:

On 03/24/11 at 2:00 PM, it was noted that the generator room in Dobbs Ferry has abundant amount of furniture, cardboard boxes, and other similar combustible items stored along with the generator.

Finding was verified with Staff #25, Staff #26 and Staff #30.

Note: Subsection 5-11.1of NFPA 110 states that:
The room in which the EPS equipment is located shall not be used for storage purposes.

Based on observations and record review, it was noted that the facility provides general anesthesia in Andrus Pavilion.
(NFPA 99 - 1999 defines "Critical Care Areas" (i.e., Operating Rooms where NFPA 99 defined "invasive procedures" are performed and patients are connected to line operated patient care-related electrical appliances.)
Based on observation and staff interview, it was determined that the emergency generator 650kVA in the Andrus Pavilion was not wired as a Type I EES (essential electrical system). NFPA 99 3-4.

Findings include:

Based on interviews with Staff #25, staff suggested that the wiring configuration in the Andrus Pavilion for the Type I EES (650 K generator) may not be compliant with 1999 NFPA 99 3-4.2.2.1. The specific issue involved was the separation of the generator branches into a life safety, critical, and equipment system for the facility. Discussion revealed that the generator is as it was installed in 1980's. The facility operates a ventilator dependent unit and as such, requires a Type I EES.

Therefore, the wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System, and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch.

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