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Based on observation, Westchester Medical Center Bradhurst Building's construction type was not maintained.

The finding was:

On the afternoon of 9/3/2014 observation within the Bradhurst Building Pump/Mechanical Room revealed that the fire resistive coating on a structural steel I-beam was missing at several spots, generally where a clasp had been attached to the beam. The lack of the sprayed-on coating compromises the fire resistive integrity of the beam.

Note: The structural beams need to be maintained with a 2-hour fire resistive rating, as the building construction type has been certified as II (2,2,2) in accordance with NFPA 220 - Standard on Types of Building Construction.

NFPA 101 (2000 edition) Section 4.5.7

Based on observation and staff interview, the Mid-Hudson Valley Division of Westchester Medical Center's corridors were not separated by walls with a one hour fire resistance rating.

The findings include:

On the afternoon of 8/27/2014 observation during a life safety tour of the Mid-Hudson Valley Division of Westchester Medical Center's 1 hour fire-rated walls it was revealed that:

a) in the vicinity of the 1st. Floor Medical Gas Room there was an unsealed conduit penetration.

b) in the vicinity of the 1st. Floor Radiology Waiting Area there was a partially sealed conduit penetration and a partially sealed BX cable penetration.

c) there was an unsealed BX cable penetration within the 45 minute fire-rated door between the 3rd. Floor of the Roosevelt Building and the 3rd. Floor of the Thorne Building.

d) there was an unsealed data wire bundle penetration within the 1 hour fire-rated wall located over the 45 minute fire-rated Entrance/Exit door of the Progressive Care Unit.

These findings were concurrently verified by the Staff #1, the Senior Director of Support Services.

A. Based on observation and staff interview, the Mid-Hudson Valley Division of Westchester Medical Center's 3/4 hour (45 minutes) fire-rated corridor doors were not maintained.

The findings include:

1. On the morning of 8/19/2014 observation in the Kitchen revealed that the Chemical Room's 3/4 hour fire-rated door did not positively latch.

2. On the morning of 8/19/2014 observation in the Kitchen revealed that the Staff Entrance 3/4 hour fire-rated Door to the Kitchen was dented/damaged.

These findings were concurrently verified by the Staff #1, the Senior Director of Support Services.

B. Based on observation and staff interview, Westchester Medical Center's 3/4 hour (45 minutes) fire-rated corridor doors were not maintained.

1. On the afternoon of 9/2/2014 observation within the Ambulatory Care Center revealed that North Exit Door was damaged and would not self latch. It was also observed that the North Exit Door and the Post-Op Exit Door within this center had signage stating "Not an exit", although there was an "Exit" light over the door.

2. On the afternoon of 9/3/2014 observation revealed that the Au Bon Soda Room's 3/4 hour fire-rated door did not self latch.

3. On the afternoon of 9/3/2014 observation revealed that the Gift Shop Entrance Door was open and it had no self closure installed on it.

These findings were concurrently verified by the Staff #2, the Director of Engineering and Construction.

Based on observations and staff interview, the Mid-Hudson Valley Division of Westchester Medical Center's smoke barriers were not constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

The findings include:

1. On the afternoon of 8/27/2014 observation during a life safety tour of the facility's 1/2 hour rated smoke barriers it was revealed that:

a) in the vicinity of the 1st. Floor Director of Imaging Office there were 3 unsealed conduit penetrations and 1 unsealed data wire penetration.

b) in the vicinity of 4th. Floor Community Room #1 the outer edges of a wall duct was not sealed.

These findings were concurrently verified by the Staff #1, the Senior Director of Support Services.

Based on observation, Westchester Medical Center Bradhurst Building's one hour fire rated construction (with ¾ hour fire-rated doors) in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas was not maintained.

The finding was:

On the afternoon of 9/3/2014 observation within the Bradhurst Building revealed that the fire-rated doors protecting the Pump/Mechanical Room were not fully self-closing. It was also observed that a single leaf door, and one leaf of a double door were impeded from fully closing and latching since they contacted the floor.

NFPA 101 (2000 edition) Sections 38.3.2.1, 8.4.1

Based on record review and staff interview, Westchester Medical Center Bradhurst Building's fire alarm system was not tested and maintained in accordance with the applicable requirements of NFPA 70 and 72.

The finding was:

On the afternoon of 9/3/2014 record review of the Bradhurst Buildings fire alarm system periodic test report (i.e., the AFA Protective Systems dated 2/1/14 & 2/8/14, received on 9/5/14) revealed that the fire alarm system lacked certain components of a maintenance and testing program, as required under NFPA 70 and NFPA 72. This report does not list the specific devices tested (nor indicate a test result for each device/location, but rather only indicates the aggregate numbers of devices tested).

NFPA 101 (2000 edition) Sections 38.3.4.1, 9.6.1.4, 9.6.1.7, NFPA 70 National Electrical Code (1999 edition), NFPA 72 National Fire Alarm Electrical Code (1999 edition)

Based on observation and staff interview, Westchester Medical Center's automatic sprinkler system was not installed in accordance with NFPA 13, Standard for the Installations of Sprinkler Systems, to provide coverage for all portions of the building.

The finding was:

On the afternoon of 9/9/2014 observation in the Cafeteria pass through to the exit door revealed that a sprinkler head was installed approximately 1" from the wall.

This finding was concurrently verified by the Staff #2, the Director of Engineering and Construction.

Based on observation and staff interview, the ansul extinguish system was not accessible for monitoring.

Finding was:

On the morning of 9/2/2014 during a tour of the basement of the main hospital, it was noted that the gauge of the ansul extinguish system was observed to be greater than 9 feet above the floor which is too high to be watched or to be monitored.

This finding was verified with staff #4, the Vice President of Facilities. who acknowledged it.

Based on record review and staff interview, Westchester Medical Center's heating, ventilating, and air conditioning did not comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2.

The finding was:

On the afternoon of 9/5/2014 record review of the 2014 Fire and Smoke Dampers Report for Westchester Medical Center Behavioral Health Center/Taylor Care Center revealed that out of 633 total fire and smoke dampers there were 137 dampers that either failed or were inaccessible. Specifically, 92 devices failed and 127 devices were not accessible. There was no records indicating that these 224 dampers were ever corrected/tested.

This finding was concurrently verified by the Staff #3, the Director of Engineering and Maintenance.

Based on observation and staff interview, Westchester Medical Center's means of egress were not continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

The finding were:

1. On the morning of 9/2/2014 during a tour of the basement of the main hospital, it was noted that the housekeeping corridor leading to the kitchen was partly blocked by clean linen cart and plastic garbage container. Both the clean linen cart and the garbage container were approximately measured 4 feet x 6 feet x 3 feet.

Also, there were many boxes (greater than 100 boxes) left unattended in the house keeping corridor.

This finding was concurrently verified by Staff #4, the Senior Vice President of Facilities.

2. On the morning of 9/3/2014 observation in the Medical Records Storage Room revealed that access to the South Exit of this room was blocked by 10 boxes that were being stored on the ground.

This finding was concurrently verified by Staff #3, the Director of Engineering and Maintenance.

Based on observation, Westchester Medical Center Bradhurst Building's medical gas storage area was not protected in accordance with NFPA 99, Standards for Health Care Facilities.

The findings was:

On the afternoon of 9/3/2014 observation within the Bradhurst Building revealed that the
medical gas storage/administration area, which included oxygen tanks, was not enclosed by a one-hour fire rated barrier to separate the room from the remainder of the building. Observation also revealed that there were multiple mailbox insertions that went through one of the walls to the egress corridor on the other side, and created non rated protrusions through this wall.

Note: These medical gasses serve the Pediatric Pulmonary Lab, which is also located on the Atrium level, but not adjacent to the medical gas storage/administration area.

NFPA 101 (2000 edition) Sections 38.3.2, 6.2

Based on observation, Westchester Medical Center Bradhurst Building's no smoking signs were not located in areas where oxygen is used or stored in accordance with 19.3.2.4, NFPA 99, 8.6.4.2.

The finding was:

On the afternoon of 9/3/2014 observation revealed that the Bradhurst Buildings medical gas storage/administration area, which included oxygen tanks, lacked a precautionary sign and a no smoking sign.

NFPA 101 (2000 edition) Sections 4.6.1.2, 18.3.2.4; NFPA 99 (2012 edition) Section 5.1.3.1.9

27522


A. Based on observation and staff interview, the Mid-Hudson Valley Division of Westchester Medical Center's Type I Essential Electrical System (EES) was not divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.

The finding was:

On the morning of 8/29/2014 observation revealed that an Emergency Department Equipment Panel, identified as EQED1, had one (1) Fire Damper and (1) Smoke Damper identified on the panel sheet. These two (2) circuit breakers belong to the Life Safety Branch.

This finding was concurrently verified by the Staff #1, the Senior Director of Support Services.


B. Based on observation, record review and staff interview, Westchester Medical Center's Type I Essential Electrical System (EES) was not divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.

The finding was:

Throughout the survey of the facility observation and concurrent record review revealed that the Essential Electrical System (EES) for the main hospital building, including Macy Pavilion, was not fully designed as a Type I EES system and is not divided into a life safety branch, a critical branch and an (emergency ) equipment branch, in accordance with NFPA 99 (1999 edition) Section 3.4, 3.4.2.2.2

Note: This issued was cited on the 1/13/12 Title 18 survey under K145. An extended corrective action to correct this was put into place, and the project to re-equip and re-wire these buildings is ongoing (via approved $1.6 million Certificate of Need project # 102389). Additionally, a time limited waiver approved by CMS is in place regarding the issue. The current plan of correction shall update the progress of the correction, and give an anticipated completion date. Also, a renewal of the waiver may be required.

Based on observation, Westchester Medical Center Bradhurst Building's construction type was not maintained.

The finding was:

On the afternoon of 9/3/2014 observation within the Bradhurst Building Pump/Mechanical Room revealed that the fire resistive coating on a structural steel I-beam was missing at several spots, generally where a clasp had been attached to the beam. The lack of the sprayed-on coating compromises the fire resistive integrity of the beam.

Note: The structural beams need to be maintained with a 2-hour fire resistive rating, as the building construction type has been certified as II (2,2,2) in accordance with NFPA 220 - Standard on Types of Building Construction.

NFPA 101 (2000 edition) Section 4.5.7

Based on observation and staff interview, the Mid-Hudson Valley Division of Westchester Medical Center's corridors were not separated by walls with a one hour fire resistance rating.

The findings include:

On the afternoon of 8/27/2014 observation during a life safety tour of the Mid-Hudson Valley Division of Westchester Medical Center's 1 hour fire-rated walls it was revealed that:

a) in the vicinity of the 1st. Floor Medical Gas Room there was an unsealed conduit penetration.

b) in the vicinity of the 1st. Floor Radiology Waiting Area there was a partially sealed conduit penetration and a partially sealed BX cable penetration.

c) there was an unsealed BX cable penetration within the 45 minute fire-rated door between the 3rd. Floor of the Roosevelt Building and the 3rd. Floor of the Thorne Building.

d) there was an unsealed data wire bundle penetration within the 1 hour fire-rated wall located over the 45 minute fire-rated Entrance/Exit door of the Progressive Care Unit.

These findings were concurrently verified by the Staff #1, the Senior Director of Support Services.

A. Based on observation and staff interview, the Mid-Hudson Valley Division of Westchester Medical Center's 3/4 hour (45 minutes) fire-rated corridor doors were not maintained.

The findings include:

1. On the morning of 8/19/2014 observation in the Kitchen revealed that the Chemical Room's 3/4 hour fire-rated door did not positively latch.

2. On the morning of 8/19/2014 observation in the Kitchen revealed that the Staff Entrance 3/4 hour fire-rated Door to the Kitchen was dented/damaged.

These findings were concurrently verified by the Staff #1, the Senior Director of Support Services.

B. Based on observation and staff interview, Westchester Medical Center's 3/4 hour (45 minutes) fire-rated corridor doors were not maintained.

1. On the afternoon of 9/2/2014 observation within the Ambulatory Care Center revealed that North Exit Door was damaged and would not self latch. It was also observed that the North Exit Door and the Post-Op Exit Door within this center had signage stating "Not an exit", although there was an "Exit" light over the door.

2. On the afternoon of 9/3/2014 observation revealed that the Au Bon Soda Room's 3/4 hour fire-rated door did not self latch.

3. On the afternoon of 9/3/2014 observation revealed that the Gift Shop Entrance Door was open and it had no self closure installed on it.

These findings were concurrently verified by the Staff #2, the Director of Engineering and Construction.

Based on observations and staff interview, the Mid-Hudson Valley Division of Westchester Medical Center's smoke barriers were not constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

The findings include:

1. On the afternoon of 8/27/2014 observation during a life safety tour of the facility's 1/2 hour rated smoke barriers it was revealed that:

a) in the vicinity of the 1st. Floor Director of Imaging Office there were 3 unsealed conduit penetrations and 1 unsealed data wire penetration.

b) in the vicinity of 4th. Floor Community Room #1 the outer edges of a wall duct was not sealed.

These findings were concurrently verified by the Staff #1, the Senior Director of Support Services.

Based on observation, Westchester Medical Center Bradhurst Building's one hour fire rated construction (with ¾ hour fire-rated doors) in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas was not maintained.

The finding was:

On the afternoon of 9/3/2014 observation within the Bradhurst Building revealed that the fire-rated doors protecting the Pump/Mechanical Room were not fully self-closing. It was also observed that a single leaf door, and one leaf of a double door were impeded from fully closing and latching since they contacted the floor.

NFPA 101 (2000 edition) Sections 38.3.2.1, 8.4.1

Based on record review and staff interview, Westchester Medical Center Bradhurst Building's fire alarm system was not tested and maintained in accordance with the applicable requirements of NFPA 70 and 72.

The finding was:

On the afternoon of 9/3/2014 record review of the Bradhurst Buildings fire alarm system periodic test report (i.e., the AFA Protective Systems dated 2/1/14 & 2/8/14, received on 9/5/14) revealed that the fire alarm system lacked certain components of a maintenance and testing program, as required under NFPA 70 and NFPA 72. This report does not list the specific devices tested (nor indicate a test result for each device/location, but rather only indicates the aggregate numbers of devices tested).

NFPA 101 (2000 edition) Sections 38.3.4.1, 9.6.1.4, 9.6.1.7, NFPA 70 National Electrical Code (1999 edition), NFPA 72 National Fire Alarm Electrical Code (1999 edition)

Based on observation and staff interview, Westchester Medical Center's automatic sprinkler system was not installed in accordance with NFPA 13, Standard for the Installations of Sprinkler Systems, to provide coverage for all portions of the building.

The finding was:

On the afternoon of 9/9/2014 observation in the Cafeteria pass through to the exit door revealed that a sprinkler head was installed approximately 1" from the wall.

This finding was concurrently verified by the Staff #2, the Director of Engineering and Construction.

Based on observation and staff interview, the ansul extinguish system was not accessible for monitoring.

Finding was:

On the morning of 9/2/2014 during a tour of the basement of the main hospital, it was noted that the gauge of the ansul extinguish system was observed to be greater than 9 feet above the floor which is too high to be watched or to be monitored.

This finding was verified with staff #4, the Vice President of Facilities. who acknowledged it.

Based on record review and staff interview, Westchester Medical Center's heating, ventilating, and air conditioning did not comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2.

The finding was:

On the afternoon of 9/5/2014 record review of the 2014 Fire and Smoke Dampers Report for Westchester Medical Center Behavioral Health Center/Taylor Care Center revealed that out of 633 total fire and smoke dampers there were 137 dampers that either failed or were inaccessible. Specifically, 92 devices failed and 127 devices were not accessible. There was no records indicating that these 224 dampers were ever corrected/tested.

This finding was concurrently verified by the Staff #3, the Director of Engineering and Maintenance.

Based on observation and staff interview, Westchester Medical Center's means of egress were not continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

The finding were:

1. On the morning of 9/2/2014 during a tour of the basement of the main hospital, it was noted that the housekeeping corridor leading to the kitchen was partly blocked by clean linen cart and plastic garbage container. Both the clean linen cart and the garbage container were approximately measured 4 feet x 6 feet x 3 feet.

Also, there were many boxes (greater than 100 boxes) left unattended in the house keeping corridor.

This finding was concurrently verified by Staff #4, the Senior Vice President of Facilities.

2. On the morning of 9/3/2014 observation in the Medical Records Storage Room revealed that access to the South Exit of this room was blocked by 10 boxes that were being stored on the ground.

This finding was concurrently verified by Staff #3, the Director of Engineering and Maintenance.

Based on observation, Westchester Medical Center Bradhurst Building's medical gas storage area was not protected in accordance with NFPA 99, Standards for Health Care Facilities.

The findings was:

On the afternoon of 9/3/2014 observation within the Bradhurst Building revealed that the
medical gas storage/administration area, which included oxygen tanks, was not enclosed by a one-hour fire rated barrier to separate the room from the remainder of the building. Observation also revealed that there were multiple mailbox insertions that went through one of the walls to the egress corridor on the other side, and created non rated protrusions through this wall.

Note: These medical gasses serve the Pediatric Pulmonary Lab, which is also located on the Atrium level, but not adjacent to the medical gas storage/administration area.

NFPA 101 (2000 edition) Sections 38.3.2, 6.2

Based on observation, Westchester Medical Center Bradhurst Building's no smoking signs were not located in areas where oxygen is used or stored in accordance with 19.3.2.4, NFPA 99, 8.6.4.2.

The finding was:

On the afternoon of 9/3/2014 observation revealed that the Bradhurst Buildings medical gas storage/administration area, which included oxygen tanks, lacked a precautionary sign and a no smoking sign.

NFPA 101 (2000 edition) Sections 4.6.1.2, 18.3.2.4; NFPA 99 (2012 edition) Section 5.1.3.1.9

27522


A. Based on observation and staff interview, the Mid-Hudson Valley Division of Westchester Medical Center's Type I Essential Electrical System (EES) was not divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.

The finding was:

On the morning of 8/29/2014 observation revealed that an Emergency Department Equipment Panel, identified as EQED1, had one (1) Fire Damper and (1) Smoke Damper identified on the panel sheet. These two (2) circuit breakers belong to the Life Safety Branch.

This finding was concurrently verified by the Staff #1, the Senior Director of Support Services.


B. Based on observation, record review and staff interview, Westchester Medical Center's Type I Essential Electrical System (EES) was not divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.

The finding was:

Throughout the survey of the facility observation and concurrent record review revealed that the Essential Electrical System (EES) for the main hospital building, including Macy Pavilion, was not fully designed as a Type I EES system and is not divided into a life safety branch, a critical branch and an (emergency ) equipment branch, in accordance with NFPA 99 (1999 edition) Section 3.4, 3.4.2.2.2

Note: This issued was cited on the 1/13/12 Title 18 survey under K145. An extended corrective action to correct this was put into place, and the project to re-equip and re-wire these buildings is ongoing (via approved $1.6 million Certificate of Need project # 102389). Additionally, a time limited waiver approved by CMS is in place regarding the issue. The current plan of correction shall update the progress of the correction, and give an anticipated completion date. Also, a renewal of the waiver may be required.